Atlas of Postsurgical Neuroradiology - Imaging of The Brain, Spine, Head, and Neck (PDFDrive)

Daniel Thomas Ginat
Per-Lennart A. Westesson
Editors
Atlas of Postsurgical
Neuroradiology
Imaging of the Brain,

Spine, Head, and Neck
Second Edition
123
Atlas of Postsurgical Neuroradiology
Daniel Thomas Ginat
Editors
Atlas of Postsurgical
Neuroradiology
Imaging of the Brain, Spine, Head,
and Neck
Second Edition
Editors
Daniel Thomas Ginat Per-Lennart A. Westesson
Department of Radiology Division of Diagnostic and
University of Chicago Interventional Neuroradiology
Pritzker School of Medicine University of Rochester School of
Chicago, IL Medicine and Dentistry
USA Rochester, NY
USA
ISBN 978-3-319-52340-8 ISBN 978-3-319-52341-5 (eBook)

DOI 10.1007/978-3-319-52341-5
Library of Congress Control Number: 2017943020
© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
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Printed on acid-free paper
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The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to my parents, Roselyne and Jonathan.
Daniel Thomas Ginat
This book is dedicated to my wife Ann-Margret and our

children Karin, Oscar, and Nils.
Foreword
Radiologists and clinicians caring for patients have a plethora of references

that provide educational tools for imaging studies illustrating neuroanatomy
and many forms of neurological and neurosurgical disease processes.
However, even those who are well versed in interpreting imaging examina-
tions often find assessment of imaging studies in the postoperative patient
difficult. Information on imaging findings in the postoperative patient is
indeed available but, in scattered locations, making ready access for radiolo-
gists difficult.
One realm in which radiologists must constantly update their knowledge is
that of imaging devices: their composition and appearance, their correct loca-
tion, and their proper functioning. Such devices are numerous and have many
different appearances. Increasingly, radiologists are requested to interpret
imaging studies designed to assess the status of devices used in care of patients.
These studies are intended to answer questions such as “Is the device properly
positioned?” “Is the device intact?” and “Is the device functioning properly?”
Resources that can provide information relevant to answering such questions
are scarce and cannot generally be found at a single source of information.
Another area in which radiologists need to regularly update their knowl-
edge base is the appearance of the postoperative surgical site. New surgical
techniques continually come into use; they may present a baffling appearance
to radiologists unfamiliar with their details. As a result, the potential for incor-
rect reporting of imaging findings is substantial. An up-to-date compendium
of normal surgical findings for a given procedure would be of great use. Yet
another potential source of consternation for those interpreting postoperative
imaging studies is assessing complications of surgical procedures. It is easy to
understand how the lack of familiarity of normal and abnormal appearances of
postoperative conditions could lead to one being mistaken for the other.
Thus, a need exists for a comprehensive source of information on these
topics. In Atlas of Postsurgical Neuroradiology, Drs. Ginat and Westesson
ably address that need by providing an in-depth and comprehensive explana-
tion of standard postoperative findings as well as a wide array of appearances
of therapeutic devices. The assembly of information on these topics in a sin-
gle reference will, no doubt, prove valuable to radiologists and physicians
involved in postsurgical care alike.
Durham, NC, USA James M. Provenzale, M.D.
vii
Preface
In addition to updating the text according to progress that has occurred in the
relevant fields since the 5 years that have ensued since the first edition of
Atlas of Postsurgical Neuroradiology, this second edition contains more use-
ful and interesting topics. Indeed, this book includes many new images and
sections, such as robot surgery and intraoperative MRI, as well as additional
authors.
Chicago, IL, USA Daniel Thomas Ginat
ix
Acknowledgments
We thank the following individuals for contributing cases, photographs, or

insights:
Nishant Agrawal, M.D.

Jene Bohannon
Daniel Cavalcante
Kathryn Colby, M.D.
Joel Curé, M.D.
Shehenaz Ellika, M.D.
Zhen Gooi, M.D.
Melissa Guilbeau
Rajiv Gupta, M.D.
Ryder Gwinn
John W. Henson, M.D.
Justin Hugelier
Gregory Katzman, M.D., M.B.A.
Nina Klionski, M.D.
Patrik Keshishian, D.D.S.
Sarah Paengatelli
Bruno Policeni M.D.
Amy Schneider, Medtronic
Patricia Smith, N.P.
Zimmer Spine (Minneapolis, MN)
Christine Toh, M.D.
Richard White, M.D.
John Wandtke, M.D.
Tina Young Poussaint, M.D.
Jennifer Wulff, ARNP
Fatoumata Yanoga, M.D.
Juan Small, M.D.
xi
xii Acknowledgments
We also thank the following companies for providing device images:
Alcon/Novartis
Alphatec Spine
Altomed
Benvenue Medical
Cochlear Corp
Grace Medical
Hoopes Vision
Medtronic
Osmed
Paradigm Spine
Quandary Medical
Synthes
Contents
1 Imaging of Facial Cosmetic Surgery�� 1

Charles J. Schatz and Daniel Thomas Ginat
2 Imaging the Postoperative Orbit�� 31
Daniel Thomas Ginat, Gul Moonis, and Suzanne K. Freitag
3 Imaging the Paranasal Sinuses and Nasal Cavity�� 75
Daniel Thomas Ginat, Mary Elizabeth Cunnane,
and Robert M. Naclerio
4 Imaging the Postoperative Scalp and Cranium�� 117
Daniel Thomas Ginat, Ann-Christine Duhaime,
and Marc Daniel Moisi
5 Imaging the Intraoperative and Postoperative Brain�� 183
Daniel Thomas Ginat, Pamela W. Schaefer,
6 Imaging of Cerebrospinal Fluid Shunts, Drains, and
Diversion Techniques �� 259
Daniel Thomas Ginat, Per-Lennart A. Westesson,
and David Frim
7 Imaging of the Postoperative Skull Base and
Cerebellopontine Angle�� 311
Daniel Thomas Ginat, Peleg M. Horowitz, Gul Moonis,
and Suresh K. Mukherji
8 Imaging of the Postoperative Ear and Temporal Bone�� 351
Daniel Thomas Ginat, Gul Moonis, Suresh K. Mukherji,
and Michael B. Gluth
9 Imaging of Orthognathic, Maxillofacial, and
Temporomandibular Joint Surgery�� 421
and Russell Reid
10 Imaging the Postoperative Neck �� 453
Daniel Thomas Ginat, Elizabeth Blair, and Hugh D. Curtin
xiii
xiv Contents
11 Imaging of Postoperative Spine�� 523

Daniel Thomas Ginat, Ryan Murtagh, Per-Lennart A. Westesson,
Marc Daniel Moisi, and Rod J. Oskouian
12 Imaging of Vascular and Endovascular Surgery�� 627
Daniel Thomas Ginat, Javier M. Romero,
and Gregory Christoforidis
Index�� 697
Contributors
Elizabeth Blair, M.D. Department of Surgery, Section of Otolaryngology-

Head and Neck Surgery, University of Chicago, Chicago, IL, USA
Gregory Christoforidis, M.D. Department of Radiology, University of
Chicago, Chicago, IL, USA
Mary Elizabeth Cunnane, M.D. Department of Radiology, Harvard
Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
Hugh D. Curtin, M.D. Department of Radiology, Harvard Medical School,
Boston, MA, USA
Department of Radiology, Massachusetts Eye and Ear Infirmary, Boston,
MA, USA
Ann-Christine Duhaime, M.D. Department of Neurosurgery, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
Suzanne K. Freitag, M.D., M.S. Department of Ophthalmology, Harvard
Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
Daniel Thomas Ginat, M.D., M.S. Department of Radiology, University of
Chicago, Pritzker School of Medicine, Chicago, IL, USA
Michael B. Gluth, M.D. Department of Surgery, Division of Otolaryngology,
University of Chicago, Chicago, IL, USA
Peleg M. Horowitz, M.D., Ph.D. Department of Surgery, University of
Chicago, Chicago, IL, USA
Gul Moonis, M.D. Department of Radiology, Columbia University Medical
Center, New York City, NY, USA
Suresh K. Mukherji, M.D., FACR Division of Radiology, Michigan State
University, East Lansing, MI, USA
Ryan Murtagh, M.D., M.B.A Department of Radiology, Diagnostic Imaging
Moffitt Cancer Center, Tampa, FL, USA
Marc D. Moisi, M.D., M.S. Department of Neurosurgery, Swedish Neuroscience
Institute, Seattle, WA, USA
Robert M. Naclerio, M.D. Section of Otolaryngology-Head and Neck
Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
xv
xvi Contributors
Rod J. Oskouian, M.D. Department of Neurosurgery, Swedish Neuroscience

Russell Reid, M.D., Ph.D. Department of Surgery, University of Chicago,
Chicago, IL, USA
Javier M. Romero, M.D. Department of Radiology, Harvard Medical
School, Massachusetts General Hospital, Boston, MA, USA
Pamela W. Schaefer, M.D. Department of Radiology, Harvard Medical
School, Massachusetts General Hospital, Boston, MA, USA
Charles J. Schatz, M.D., FACR Beverly Wilshire Tower Advanced Imaging,
Beverly Hills, CA, USA
University of Southern California Keck School of Medicine, Los Angeles,
CA, USA
Per-Lennart A. Westesson, M.D., Ph.D., DDS Division of Neuroradiology,
University of Rochester Medical Center, Rochester, NY, USA
Imaging of Facial Cosmetic
Surgery 1
Charles J. Schatz and Daniel Thomas Ginat
1.1 verview of Facial Cosmetic

O polytetrafluoroethylene, silicone, alkyl-imide
Materials and Their Imaging gel polymer, and botulinum toxin, among
Features others.
On occasion, CT or MRI will be obtained to
A wide variety of materials have been used to evaluate complications, which include foreign
augment facial tissues in the form of implants, body granuloma formation, seroma, infection/fis-
grafts, fillers, and injectables (Fig. 1.1). The tula/draining sinus, skin atrophy, implant migra-
main types of implant and graft materials tion and extrusion, change in cosmetic result,
(Table 1.1) include solid silicone, polytetrafluo- functional alteration, vision loss, dysesthesia,
roethylene, high-density porous polyethylene, ossification, and obstructed breathing, among
bone, and fat, while the main types of fillers and others, depending on the type of implant or graft.
injectables (Table 1.2) include hyaluronic acid Alternatively, changes related to facial surgery
preparations, calcium hydroxyapatite, collagen, may be encountered incidentally on imaging.
C.J. Schatz, M.D., FACR (*)

Department of Radiology, Beverly Tower Wilshire,
Advanced Imaging, Beverly Hills, CA, USA
University of Southern California, Keck School of
Medicine, Los Angeles, CA, USA
D.T. Ginat, M.D., M.S.
Department of Radiology, University of Chicago,
Pritzker School of Medicine, Chicago, IL, USA
e-mail: dtg1@uchicago.edu
© Springer International Publishing Switzerland 2017 1
D.T. Ginat, P.-L.A. Westesson (eds.), Atlas of Postsurgical Neuroradiology,
DOI 10.1007/978-3-319-52341-5_1
2 C.J. Schatz and D.T. Ginat
Fig. 1.1 Photographs a
of various facial implants
(a, b)
b
1 Imaging of Facial Cosmetic Surgery 3
Table 1.1 Implants and grafts

Material Properties and uses Imaging appearance
Solid silicone Rubber elastomer used since 1956 CT: variable attenuation, usually more
hyperattenuating than soft tissue, but less
hyperattenuating than bone and best
discerned using bone windows
Well-tolerated MRI: very low signal intensity on T1- and
T2-weighted sequences
Indications: chin, lateral jaw, cheek, and
nose augmentation
Polytetrafluoroethylene Long-lasting, but can be removed CT: higher attenuation relative to soft
surgically tissues, but lower attenuation than bone
Indications: lower face-lift, nasal, and MRI: hypointense to fat on T1- and
forehead augmentation T2-weighted sequences
High-density porous Inert and biocompatible CT: attenuation between fat and water
polyethylene Low complication rate MRI: hypointense to fat on T1- and
T2-weighted sequences
Permanent Enhancement may occur due to
fibrovascular ingrowth
Indications: lower face and nasal
augmentation. Also used for orbital and
auricular reconstruction
Bone Used more frequently in the past for chin CT: same as normal bone elsewhere; cortex
and cheek augmentation, often in the form and trabecular can be identified unless
of “button” implants resorption has occurred
Bone or osteochondral grafts are MRI: same as bone elsewhere
sometimes used in rhinoplasty
Harvest sites include the calvarium and rib
Table 1.2 Fillers and injectables

Filler material Properties and uses Imaging appearance
Liquid silicone Analogous to intraocular silicone CT: variable attenuation, usually similar to
injection, but not currently FDA soft tissue density
approved for facial cosmesis
Permanent agent MRI: variable signal on T1 and T2 depending
on viscosity
Relatively higher risk of granuloma Decrease in signal with fat suppression
formation, particularly with non-medical
grade formulations
More conspicuous on STIR
Collagen Naturally occurring protein derived from CT: soft tissue attenuation; subcutaneous fat
purified bovine collagen given via a appears infiltrated
subdermal injection
Indications: wrinkles, scars, and lines MRI: same signal intensity as water
Lasts approximately 3–6 months (hypointense to fat on T1 and hyperintense to
fat on T2); occasional minimal peripheral
enhancement that can persist up to 2 months
Hyaluronic acid Injectable gel CT: water attenuation; subcutaneous fat

preparations appears infiltrated
FDA approved MRI: same signal intensity as water
Indications: wrinkles, scars, and lines (hypointense to fat on T1 and hyperintense to
Lasts about 6 months and can be fat on T2); occasional minimal peripheral
removed using hyaluronidase injection enhancement that can persist up to 2 months
Polytetrafluoroethylene Implanted – not injected CT: higher attenuation relative to soft tissues
Permanent, threadlike material (not MRI: hypointense to fat on T1- and
metabolized, but can be removed T2-weighted sequences
surgically)
Indications: filler in multiple sites
(nasolabial folds, lips, glabella)
Calcium US FDA approved CT: high attenuation (generally 280–700 HU)
hydroxyapatite initially; eventually the calcium resorbs,
typically incites fibrous tissue formation that
may be visible on imaging
Temporary injectable that lasts up to at MRI: similar to bone (hypointense to muscle
least 2 years on T1- and T2-weighted sequences); no
enhancement
Indications: wrinkles, lines, scars, and PET: can lead to hypermetabolic response
HIV lipoatrophy
Alkyl-imide gel Injectable, biocompatible, nontoxic, CT: water attenuation masses surrounded by
polymer nonallergenic soft tissue filler thin collagen capsule
Uses: HIV lipoatrophy and rejuvenation MRI: same signal intensity as water
(hypointense to fat on T1 and hyperintense to
fat on T2)
Botulinum toxin Neurotoxin for the temporary CT: nil
improvement of glabellar lines
Intramuscular injection (corrugator and MRI: nil
procerus muscles; 5 sites – 0.1 ml each)
Maximum effect at 30 days. Lasts up to
6 months
1.2 Forehead Augmentation implants have corrugated edges and central perfora-
tions in order to optimize fixation and prevent
1.2.1 Discussion capsular contraction. Fillers, such as calcium

hydroxyapatite, also have a role in forehead aug-
Forehead augmentation is performed for improving mentation. These materials can be inserted in the
the upper facial contour. A variety of alloplastic midline (Figs. 1.2 and 1.3), lateral brow (Fig. 1.4),
implants have been used for this purpose, including or both. Botox is another minimally invasive option
polytetrafluoroethylene and silicone. Often, silicone for reducing lines and wrinkles.
Fig. 1.2 Mid-forehead augmentation with polytetraflu

oroethylene. Axial (a) and coronal (b) CT images
demonstrate hyperattenuating linear implants in the
glabella
Fig. 1.4 Lateral brow augmentation. Coronal CT image

shows collections of calcium hydroxyapatite in the lateral
supraorbital areas (arrowheads)
Fig. 1.3 Mid-forehead augmentation with calcium hydroxy

apatite. Axial (a), coronal (b), and sagittal (c) CT images
demonstrate hyperattenuating linear implants with fuzzy
edges, which provide a gentle convex contour to the glabella
despite the flat frontal bone. A silicone dorsal nasal implant is
also present
1.3 heek and Nasolabial Fold

C often evident (Fig. 1.15). Additional manifesta-
Augmentation tions of implant-associated infections include
osteomyelitis and draining sinuses (Fig. 1.16).
1.3.1 Discussion Other complications depend on the type of mate-
rial used. In particular, liquid silicone can induce
Cheek augmentation consists of expanding the extensive inflammation, which appears as strand-
malar region, submalar region, or a combination ing or high T2 signal in the subcutaneous tissues
of these, often bilaterally. The procedure is per- (Fig. 1.17). Furthermore, injected nonmedical-
formed for soft tissue enhancement or simply for grade silicone has a particular propensity to cause
correcting a deficient or atrophic face, including scars and granulomas. These complications can
HIV lipoatrophy. A wide variety of materials develop many years after injection of the filler.
have been used for these purposes, including Hypertrophic scars can appear as bands of soft
coral implants (Fig. 1.5), silicone rubber implants tissue within the subcutaneous fat on CT
(Fig. 1.6), injectable silicone (Fig. 1.7), injectable (Fig. 1.18). Granulomas often appear as
calcium hydroxyapatite (Fig. 1.8), polytetrafluo- subcentimeter rounded or oval foci of variable
roethylene strips (Fig. 1.9), hyaluronic acid attenuation on CT (Fig. 1.19). Silicone foreign
(Fig. 1.10), collagen (Fig. 1.11), alkyl-imide gel body granulomas can contain microcalcifications
polymer (Fig. 1.12), and combination of materi- or form eggshell calcifications. Implants, such as
als (Fig. 1.13). silicone rubber, can occasionally erode through
Seromas can be present and appear as simple the bone (Fig. 1.20) and potentially result in
fluid collections surrounding the implants sinusitis. Cheek implantation can sometimes
(Fig. 1.14). Seromas typically resolve spontane- induce heterotopic bone formation (Fig. 1.21).
ously, unless there is superimposed infection. In Bone grafts can resorb over time, thereby also
such cases, the patient may present with fever diminishing cosmetic effect. Migration of fillers
and purulent drainage. On imaging, stranding of or implants can mimic mass lesions and impair
the subcutaneous fat overlying the implant is vision (Fig. 1.22).
Fig. 1.5 Cheek augmentation with coral implants. Axial

CT image shows hyperattenuating material overlying the
bilateral malar eminences
Fig. 1.7 Acne scar treatment with silicone oil filler. Axial
CT image shows punctate hyperattenuating foci of the
filler material (arrow) within the subcutaneous tissues of
the left cheek
Fig. 1.6 Silicone implant cheek augmentation. Axial CT

image shows bilateral crescent-shaped hyperattenuating
implants (arrow) over the zygomatic and maxillary bones
Fig. 1.8 Anterior face and nasolabial fold calcium

hydroxyapatite injection. There is hypermetabolism at
the site of the nasolabial fold fillers (arrows) on 18FDG-
PET/CT
Fig. 1.9 Nasolabial fold polytetrafluoroethylene filler.

Axial (a) and coronal (b) CT image shows thin strips of
hyperattenuating material in the bilateral nasolabial folds
and subcutaneous tissues (arrowheads)
a b
Fig. 1.10 Nasolabial fold hyaluronic acid augmentation. Coronal STIR (a), T1-weighted (b), and post-contrast
f at-suppressed T1-weighted (c) MR images demonstrate streaky material with high T2 signal, as well as mild enhancement
a b
c d
Fig. 1.11 Combined cheek and nasolabial fold collagen sagittal T1-weighted (d) MR images in a different patient
injection. Axial CT image (a) shows soft tissue attenua- show bilateral globular collections of collagen-based gel
tion within the bilateral malar fat pads (arrows). Axial filler (arrows), which have signal characteristics similar to
T2-weighted (b), axial post-contrast T1-weighted (c), and that of water
a b
Fig. 1.12 Polyacrylamide gel polymer treatment for HIV (arrows) with similar signal characteristics to water in the
lipoatrophy. Axial T2-weighted (a) and T1-weighted (b) right lower cheek. Gel polymer was previously removed
MR images demonstrate encapsulated clusters of material from the contralateral side
Fig. 1.13 Combined silicone implant and calcium

hydroxyapatite cheek augmentation. Axial CT image
shows silicone implants bilaterally (arrows), as well as
calcium hydroxyapatite filler (arrowheads) superficial to
the right silicone implant
Fig. 1.14 Cheek implant seroma. Axial (a) and coronal

(b) CT images show fluid in the subperiosteal surrounding
the displaced left silicone cheek implant
a b
Fig. 1.15 Cheek implant abscess. Axial (a) and coronal implant is surrounded and displaced by fluid and subcuta-
(b) CT images demonstrate left check subcutaneous fat neous stranding, while the right silicone implant is unre-
stranding and overlying skin thickening. The left silicone markable. Bilateral nasolabial fold fillers are also present
a b
c d
Fig. 1.16 Cheek implant osteomyelitis. Coronal CT adjacent to the implant (arrowheads). Post-contrast axial
image (a) shows right cheek skin dimpling overlying a (c) and coronal (d) fat-suppressed T1-weighted MR
draining sinus (arrow) adjacent to a silicone implant. images show the enhancing draining sinus beneath the
Axial CT (b) image in the bone window shows sclerotic external marker
thickening of the right anterior maxillary wall and zygoma
Fig. 1.19 Injectable silicone granulomas. Axial CT

Fig. 1.17 Inflammation. Post-contrast fat-suppressed image shows several subcentimeter nodular densities in
axial T1-weighted MR image shows diffuse enhancement the bilateral nasolabial folds and buccal space fat
in the bilateral cheek subcutaneous tissues surrounding
the filler material (liquid silicone)
a b
Fig. 1.18 Injectable silicone scars. Axial (a) and coronal (b) CT images show bilateral confluent bands of soft tissue
in the bilateral subcutaneous fat of the anterior face
Fig. 1.20 Cheek implant bone erosion and maxillary

sinus penetration. Axial CT image shows medial
migration of the right solid silicone implant into the
maxillary sinus through a bony defect (arrow) caused
by long-standing pressure changes from the implant.
There is associated mucosal thickening adjacent to the
medial tip of the implant
a b
Fig. 1.21 Cheek implant heterotopic ossification. Axial (a) and 3D (b) CT images show a nodular focus of the bone
(arrows) adjacent to the right cheek implant. This finding indicates that the surgical procedure is not recent
a b
Fig. 1.22 Hyaluronic acid eyelid migration. Axial (a) and sagittal (b) T1-weighted MRI images demonstrate hyal-
uronic acid filler in the lower eyelid, resembling a tumor (arrows)
1.4 Rhinoplasty ene (Fig. 1.27), and fillers (Fig. 1.28). The implants

are sometimes purposefully positioned such that
1.4.1 Discussion they appear asymmetric on imaging, but the cos-
metic results are considered satisfactory. Kirschner
Rhinoplasty is performed to restore or enhance the (K) wires may also be used for support when there
appearance of the nose. There are a wide variety of is total nasal collapse or septal cartilage warping.
rhinoplasty techniques, ranging from functional Although some complications are clinically evi-
versus aesthetic, open versus closed, augmentation dent, imaging after rhinoplasty is occasionally
versus reduction, and primary versus secondary. requested to evaluate complications related to olfac-
The classic open rhinoplasty features in-fractures of tory dysfunction, retained foreign body (Fig. 1.29),
the bilateral nasal processes of the maxilla, which infection (Figs. 1.30 and 1.31), implant extrusion
have a characteristic appearance on CT (Fig. 1.23). (Fig. 1.32), nerve injury (Fig. 1.33), deformity
In addition, different portions of the nose can be (Fig. 1.34), and nasal obstruction, which may be
altered (i.e., tip, dorsum, nasion, columella, or a due to collapse of the nasal valves and resultant
combination of these). Both natural and synthetic laminar flow (Fig. 1.35). Normally, airflow through
materials can be used for augmentation rhinoplasty, the nasal cavity is turbulent (Fig. 1.36). Intracranial
including cartilage grafts, bone grafts (Figs. 1.24 complications related to rhinoplasty are very rare.
and 1.25), silicone (Fig. 1.26), polytetrafluoroethyl-
Fig. 1.23 Lateral osteotomy rhinoplasty. Axial CT image

shows bilateral in-fractures of the frontal processes of the
maxilla, which are characteristic of the procedure (arrows)
a b
Fig. 1.24 Tip augmentation with the bone. Axial (a) and sagittal (b) CT images show a bone graft (arrows) in the nasal tip
a b
Fig. 1.25 Dorsal augmentation with the bone. Sagittal (a) and coronal (b) CT images show dorsal bone graft (arrows)
secured via metallic microfixation plate and screws. Premaxillary augmentation was also performed (arrowheads)
a c
b d
Fig. 1.26 Rhinoplasty with a silicone dorsal tip and colu- smaller additional piece of silicone is present to the right
mellar nasal implant. Axial (a), sagittal (b), and coronal of the main implant (arrow). Axial CT image in another
(c) CT images show an L-shaped silicone implant that patient (d) demonstrates a perforation (arrow) in the
provides dorsal, tip, and columella augmentation. A implant for sutures or to promote tissue ingrowth
a b
Fig. 1.27 Rhinoplasty with polytetrafluoroethylene used for dorsal augmentation (arrow). Bilateral osteoto-
implant. Sagittal (a) and axial (b) CT images show the mies of the frontal processes of the maxilla are also pres-
thin sheet of slightly hyperattenuating implant material ent (arrowheads)
Fig. 1.29 Retained foreign body. The patient presented

Fig. 1.28 Augmentation rhinoplasty with filler. Axial CT with swelling at the operative site. Coronal CT image
image shows the hyperattenuating hydroxyapatite within shows a metallic foreign body embedded in the right nasal
the subcutaneous tissues of the right lateral nasal wall and process of the maxilla (arrow). The metallic foreign body
dorsum (arrow) was suspected to be a broken osteotome because the other
end of the osteotome was discovered in the operating
room rhinoplasty kit
a b
Fig. 1.30 Cellulitis. The patient experienced swelling of in the subcutaneous tissues of the nose. There is no dis-
the nose after reduction rhinoplasty. Axial (a) and sagittal crete fluid collection
(b) CT images demonstrate diffuse inflammatory changes
a b
Fig. 1.31 Implant-associated abscess. Axial (a) and sagittal (b) CT images show inflammatory changes and a small
fluid collection (arrows) overlying the polytetrafluoroethylene implant
a b
Fig. 1.32 Implant extrusion.

Axial (a) and coronal (b) (c)
CT images show the
low-attenuation implant
protruding from the
dorsolateral aspect of the nose
(arrows)
Fig. 1.34 Hardware deformity. Frontal radiograph shows

a bend (arrow) in the columellar Kirschner wire after
trauma
Fig. 1.33 Cranial nerve V2 injury. The patient presented

with dysesthesia after rhinoplasty. Axial (a) and sagittal
(b) CT images demonstrate perforation of the incisive
canal by the metallic Kirschner wire (arrows)
Fig. 1.35 Nasal obstruction after rhinoplasty. Coronal

CT image shows collapse of the left external nasal valve
and a normal right external nasal valve
a b
Fig. 1.36 Normally, airflow through the nasal cavity is turbulent (red arrows) (a). Nasal obstruction results in laminar
flow of air in the nasal fossa (green arrows) (b)
1.5 Lip Augmentation (Fig. 1.38). The implants can be inserted into the
upper and/or lower lips via incisions made medial
1.5.1 Discussion to the oral commissures and threading the implants
deep to the submucosal plane. Overcorrection is
Lip augmentation is performed to achieve the perhaps the main complication of lip augmenta-
appearance of fuller lips. A wide variety of materi- tion and is clinically apparent. Conversely, lip
als have been used for lip augmentation, including atrophy can result, particularly with fat grafts.
fluid silicone, autologous fat grafts, tissue matrix, Other complications, such as implant or filler
polytetrafluoroethylene (Fig. 1.37), and fillers migration, infection, and extrusion, can also occur.
Fig. 1.38 Lip augmentation with calcium hydroxyapa-

tite. Axial CT image shows the hyperattenuating filler
Fig. 1.37 Lip augmentation with polytetrafluoroethylene
within the upper lip
implants. Axial CT image of the upper lip shows the high-
attenuation curvilinear implant within the upper lip
(arrows)
1.6 Chin and Jaw Augmentation effect (Fig. 1.45). Implant migration can also
alter cosmetic result and may be associated with
1.6.1 Discussion underlying infection. Facial CT can readily char-
acterize implant migration (Fig. 1.46). Bone for-
Mandible augmentation can be performed with mation along the periosteum overlying the chin
the chin (Figs. 1.39, 1.40, and 1.41), submental implants is not an uncommon occurrence and is
(Fig. 1.42), chin/prejowl or prejowl (Fig. 1.42), usually thin linear or punctate (Fig. 1.47).
and lateral/mandibular angle implants (Fig. 1.43), Occasionally, the new bone can become large
or a combination of these. The implants are typi- enough to alter the desired cosmetic effects. This
cally inserted between the periosteum and cortex phenomenon can be characterized via CT. The
of the mandible. Bone graft implants are less bone may be more difficult to discern on MRI,
commonly used due to the tendency to resorb since it may appear as low signal, similar to the
over time. On the other hand, high-density porous silicone implants.
polyethylene and silicone implants molded to the
contours of the underlying mandible are popular a
materials for augmentation. These can be com-
bined with other materials, such as the bone.
Screw fixation is occasionally used, particularly
for providing stability to combined grafts.
Complications include hematoma, infection,
seroma, bone erosion, and migration. Seromas
may resemble infection on imaging and can alter
the intended cosmetic effect, although this may
be transient (Fig. 1.44). Mandible implants are
sometimes intentionally positioned asymmetri-
cally, but should remain in close approximation
to the surface of the mandible. However, pressure-
induced bone erosion from the implants is abnor-
b
mal and can undermine the desired cosmetic
Fig. 1.40 Chin augmentation with silicone implant.

Axial CT (a) shows a crescent-shaped slightly hyperat-
Fig. 1.39 Chin augmentation with “button” bone graft. tenuating implant anterior to the body of the mandible
Axial CT image demonstrates a bone graft anterior to the (arrowheads). The implant (arrow) appears hypointense
mandibular symphysis (arrow) on the sagittal T1-weighted MRI (b)
Fig. 1.41 Combined bone and silicone chin implant.

Axial CT shows a crescent-shaped bone graft (arrow)
fused to the mandible. The silicone implant (arrowhead)
is positioned superficial to the bone graft
Fig. 1.42 Chin and prejowl porous polyethylene implant.

Sagittal (a) and coronal (b) CT images show implants
along the inferior edges of the mandibular body (arrow-
heads). The implants have attenuation intermediate
between fat and fluid
Fig. 1.45 Chin implant bone erosion. Sagittal CT image

Fig. 1.43 Mandibular angle implants. Axial CT image
shows the silicone implant has receded into a smooth
demonstrates bilateral silicone implants deep to the mas-
defect in the body of the mandible, resulting in diminished
seter muscles (arrowheads)
cosmetic effect and impingement upon the roots of the
teeth
Fig. 1.46 Prejowl implant migration. Coronal CT image

shows inferior displacement of the left side of the implant
(arrow)
Fig. 1.44 Chin implant seroma. Axial CT image shows

fluid surrounding the silicone implant resulting in altered
cosmetic effect
Fig. 1.47 New bone formation. Axial CT image shows

hyperattenuating material (arrow) superficial to the cleft
chin implant along the expected course of the periosteum
Further Reading Constantian MB, Clardy RB (1996) The relative impor-

tance of septal and nasal valvular surgery in correcting
airway obstruction in primary and secondary rhino-
Overview of Facial Cosmetic plasty. Plast Reconstr Surg 98(1):38–54; discussion
Materials and Their Imaging Features 55–58
Fischer H, Gubisch W (2006) Nasal valves–importance and
Chisholm BB (2005) Facial implants: facial augmentation surgical procedures. Facial Plast Surg 22(4):266–280
and volume restoration. Oral Maxillofac Surg Clin Gryskiewicz JM, Hatef DA, Bullocks JM, Stal S (2010)
North Am 17(1):77–84, vi Problems in rhinoplasty. Clin Plast Surg 37(2):
Lahiri A, Waters R (2007) Experience with Bio-alcamid, 389–399
a new soft tissue endoprosthesis. J Plast Reconstr Safian LS (1984) Cosmetic rhinoplasty: radiological fea-
Aesthet Surg 60(6):663–667 tures. Head Neck Surg 7(2):139–149
Schatz CJ, Ginat DT (2013) Imaging of cosmetic facial Schatz CJ, Ginat DT (2014) Imaging features of rhino-
implants and grafts. AJNR Am J Neuroradiol plasty. AJNR Am J Neuroradiol 35(2):216–222
34(9):1674–1681
Lip Augmentation
Forehead Augmentation
Ousterhout DK, Zlotolow IM (1990) Aesthetic improve-
Maas CS (2006) Botulinum neurotoxins and injectable fill- ment of the forehead utilizing methyl methacrylate
ers: minimally invasive management of the aging onlay implants. Aesthetic Plast Surg 14(4):281–285
upper face. Facial Plast Surg Clin North Am 14(3): Sarnoff DS, Saini R, Gotkin RH (2008) Comparison of
241–245 filling agents for lip augmentation. Aesthet Surg
Ousterhout DK, Zlotolow IM (1990) Aesthetic improve- J 28(5):556–563
ment of the forehead utilizing methyl methacrylate Segall L, Ellis DA (2007) Therapeutic options for lip aug-
onlay implants. Aesthetic Plast Surg 14(4):281–285 mentation. Facial Plast Surg Clin North Am
Wong JK (2010) Forehead augmentation with alloplastic 15(4):485–490, vii
implants. Facial Plast Surg Clin North Am 18(1): Wong JK (2010) Forehead augmentation with alloplastic
71–77 implants. Facial Plast Surg Clin North Am 18(1):
71–77
Cheek and Nasolabial Fold

Augmentation Jaw Augmentation
Bastidas N, Zide BM (2010) The treachery of mandibular

Constantinides MS, Galli SK, Miller PJ, Adamson PA
angle augmentation. Ann Plast Surg 64(1):4–6
(2000) Malar, submalar, and midfacial implants.
Choe KS, Stucki-McCormick SU (2000) Chin augmenta-
Facial Plast Surg 16(1):35–44
tion. Facial Plast Surg 16(1):45–54
Garner JM, Jordan JR (2008) An unusual complication of
Godin M, Costa L, Romo T, Truswell W, Wang T, Williams
malar augmentation. J Plast Reconstr Aesthet Surg
E (2003) Gore-Tex chin implants: a review of 324
61(4):428–430
cases. Arch Facial Plast Surg 5(3):224–227
Ginat DT, Schatz CJ (2013) Imaging of silastic cheek
Ousterhout DK (1991) Mandibular angle augmentation
implant penetration into the maxillary sinus. JAMA
and reduction. Clin Plast Surg 18(1):153–161
Otolaryngol Head Neck Surg 139(2):199–201
Romo T 3rd, Baskin JZ, Sclafani AP (2001) Augmentation
Hönig J (2008) Cheek augmentation with Bio-alcamid in
of the cheeks, chin and pre-jowl sulcus, and nasolabial
facial lipoatrophy in HIV seropositive patients.
folds. Facial Plast Surg 17(1):67–78
J Craniofac Surg 19(4):1085–1088
Semergidis TG, Migliore SA, Sotereanos GC (1996)
Alloplastic augmentation of the mandibular angle.
J Oral Maxillofac Surg 54(12): 1417–1423
Rhinoplasty
Berghaus A, Stelter K (2006) Alloplastic materials in rhi-

noplasty. Curr Opin Otolaryngol Head Neck Surg
14(4):270–277
Imaging the Postoperative Orbit
2
Daniel Thomas Ginat, Gul Moonis,
and Suzanne K. Freitag
2.1 Eyelid Weights to the tarsus in the upper eyelid, enabling more
complete eyelid closure (Fig. 2.1). The implants
2.1.1 Discussion generally produce considerable metal streak arti-
fact on CT. Gold and platinum eyelid weights are
Facial nerve deficits can lead to keratitis secondary considered MRI compatible. Complications
to lagophthalmos and decreased lacrimal gland related to eyelid weight implantation include
secretions. Implantable platinum and gold infection, allergic reaction, migration, and extru-
weights are available in various sizes and shapes, sion. Closure of the orbicularis oculi muscle over
including thin profile. Eyelid weights are placed the implant reduces the risk of extrusion.
deep to the orbicularis oculi muscle and sutured
D.T. Ginat, M.D., M.S. (*)

G. Moonis, M.D
Department of Radiology, Columbia Presbyterian,
New York, NY, USA
S.K. Freitag, M.D.
Department of Ophthalmology, Massachusetts Eye
and Ear Infirmary, Harvard Medical School, Boston,
MA, USA

DOI 10.1007/978-3-319-52341-5_2
32 D.T. Ginat et al.
a b
Fig. 2.1 Eyelid weight. The patient has a history of left (arrows), which produces extensive streak artifact.
cranial nerve VII palsy. Frontal radiograph (a) shows a Photograph of various sizes of gold eyelid weight
left eyelid weight containing three suture holes (arrows). implants (c) (Courtesy of Osmed)
Sagittal CT image (b) shows a left upper eyelid weight
2 Imaging the Postoperative Orbit 33
2.2 Palpebral Springs via orbitotomy and consists of a palpebral branch

and an orbital branch connected by a spring
2.2.1 Discussion mechanism. The positioning and function of the
device can be readily assessed on radiographs
Palpebral springs may rarely be obtained in the open and closed lid positions,
used to treat patients with lagophthalmos second- whereby the palpebral branch is expected to
ary to facial nerve palsy. The device is implanted descend with lid closure (Fig. 2.2).
a b
c d
Fig. 2.2 Eyelid spring. Open (a) and closed (b) lid frontal There are also stigmata of Paget’s disease in the skull.
and open (c) and closed (d) lid lateral radiographs show Axial CT images (e, f) in a different patient show the
the spring device to be well seated and functional. The lower limb (arrow) of the spring properly positioned
palpebral branch (arrows) is noted to descend with respect along the inner surface of the upper eyelid and the upper
to the orbital branch (arrowheads) during lid closure. limb (arrowhead) implanted in the orbital roof
e f
Fig. 2.2 (continued)
2.3 rontalis Suspension Ptosis

F is used to create a subcutaneous attachment
Repair between the eyelid and the frontalis muscle.
Expanded polytetrafluoroethylene (ePTFE) strips
2.3.1 Discussion are visible on CT as hyperattenuating material
configured as a sling in the upper eyelid (Fig. 2.3)
Frontalis suspension may be used to elevate in order to suspend the eyelid to the frontalis
severely drooping eyelids in cases where the muscle. Potential complications include infection
levator palpebrae superioris muscle is weak. In and granuloma formation.
this procedure, autologous or alloplastic material
a b
Fig 2.3 Frontalis suspension ptosis repair. The patient is CT images show the hyperattenuating sling in the upper
a child with a history of bilateral ptosis due to Marcus eyelids (arrows)
Gunn jaw-winking syndrome. Axial (a) and sagittal (b)
2.4 Orbital Wall Reconstruction avoid eyelid incisions. Wedge implants can be
and Augmentation used to augment orbital volume in patients with
enophthalmos (Fig. 2.8). Transnasal wires can
2.4.1 Discussion also be inserted to stabilize the medial canthus in
trauma patients (Fig. 2.9). The role of imaging
Traditionally, autologous cartilage or bone after orbital fracture repair is mainly to asses for
(Fig. 2.4), silicone sheet implants (Fig. 2.5), and complications, which may include infection,
metal plates or mesh (Fig. 2.6) have been used for hematic cyst formation, implant deformity, and
orbital wall fracture repair. More recent implant malpositioning, which may be accompanied by
technology, including porous polyethylene mate- mucocele or nasolacrimal duct cyst formation
rials (Fig. 2.7), has resulted in improved biocom- due to obstruction and cerebrospinal fluid
patibility. The porous structure enables rapid (Figs. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, and
ingrowth of vascular structures, soft tissues, and 2.17). The leaks can be associated with compres-
bone. Furthermore, endoscopic transantral sion of orbital contents, but can resolve
approaches are increasingly used in order to spontaneously.
Fig. 2.4 Bone graft. Coronal CT image shows graft

Fig. 2.5 Silicone implant. Coronal CT image shows left
(arrow) harvested from the iliac bone used to reconstruct
orbital floor fracture reconstruction with silicone implant
the left orbital floor (Courtesy of Gregory Katzman MD,
(arrow)
MBA)
a b
Fig. 2.6 Titanium mesh. Coronal (a) and 3D CT (b) images show left orbital floor fracture repair with titanium mesh
(arrow) and inferior orbital rim fracture with malleable titanium plate (arrowhead)
a b
Fig. 2.7 Porous polyethylene implant. Coronal CT image inferior rectus muscle. The implant (arrow) appears as
(a) shows the intermediate-attenuation sheet implant low signal intensity on the sagittal T1-weighted MRI (b)
(arrow) positioned along the right orbital floor beneath the
Fig. 2.9 Medial canthus stabilization. Axial CT image

shows numerous healed left orbital fractures that involved
the medial canthus, which is secured by a transnasal metal
wire (arrow)
Fig. 2.8 Wedge implants. Sagittal T1-weighted (a) and

coronal T2-weighted (b) MR images show the two low-
intensity nearly parallel lines of the implant in the floor of
the left orbit (arrows) Fig. 2.10 Infection. Coronal post-contrast CT image
shows diffuse right pre- and postseptal orbital cellulitis
following recent medial and inferior orbital floor fracture
repair with titanium mesh
Fig. 2.11 Hematic cyst. Coronal CT image shows a right

inferior intraorbital lenticular-shaped fluid collection
(arrow) along the surface of a silastic plate Fig. 2.12 Mesh deformity. Coronal CT image shows
deformity of the orbital floor titanium mesh implant
(arrow)
a b
Fig. 2.13 Inferiorly positioned mesh. The patient presented with enophthalmos after left inferior orbital wall repair
with titanium mesh. Coronal (a) and sagittal (b) CT images show inferior displacement of the left orbital mesh (arrows)
Fig. 2.14 Rectus muscle impingement. Coronal CT

image shows lateral right medial orbital wall titanium Fig. 2.16 Mucocele secondary to malpositioned
mesh impinging upon the swollen medial rectus muscle implants. Coronal CT image shows an expansile left max-
(arrow). There is also persistent herniation of right orbital illary opacity (*) and obstruction of the infundibulum by
contents the orbital floor reconstruction plates
Fig. 2.15 Nasolacrimal duct obstruction. Axial CT

image shows dilation of the right lacrimal sac (arrow) sec-
ondary to obstruction by titanium mesh
Fig. 2.17 Cerebrospinal fluid leak. The patient under-

went biopsy of a suspect orbital roof lesion with mesh
reconstruction of the orbital roof. Coronal STIR MR
image shows a fluid collection in the superior left orbit
(arrow), with compression of the orbital contents
2.5 Orbital Decompression paranasal sinuses may also be observed on

and Expansion follow-up imaging. Serious complications related
for Dysthyroid Orbitopathy to orbital decompression occur in 3–5% of cases
depending on the particular technique and include
2.5.1 Discussion chronic sinusitis, meningitis, optic neuropathy,
orbital cellulitis, hemorrhage, nasolacrimal duct
Orbital decompression for dysthyroid orbitopa- obstruction, and inadequate proptosis reduction.
thy serves to reduce proptosis and intraocular In addition, excess herniation of orbital contents
pressure and improve compressive optic through the surgical defects can result in
neuropathy. Bone from the medial, lateral, or
obstructed paranasal sinus secretions (Fig. 2.19).
inferior orbital walls may be removed via a vari- Diplopia from displacement of orbital contents,
ety of endonasal or external approaches including the extraocular muscles occurs in up to
(Fig. 2.18). The enlarged orbital fat and rectus 25% of patients.
muscles can then bulge through these defects, Another option for treating exophthalmos in
resulting in a decrease in intraorbital pressure. A patients with dysthyroid orbitopathy is to expand
transnasal endoscopic approach is commonly the orbital vault anteriorly, which can be accom-
implemented for inferior and medial wall decom- plished using augmentation implants attached to
pression. As a result, resection of a portion of the the orbital rim (Fig. 2.20).
a b
Fig. 2.18 Medial and lateral orbital wall decompression. Axial (a) and coronal (b) CT images show surgical defects in
the bilateral medial, inferior, and lateral bony orbital walls. Note the enlarged rectus muscles
Fig. 2.19 Paranasal sinus obstruction after orbital

decompression. The patient presents with left sinus pres-
sure after orbital decompression for dysthyroid orbitopa-
b
thy. Coronal CT image shows obstructed left maxillary
sinus secretions secondary to obstruction by inferior
extension of the orbital fat (arrow) through the surgical
defect
Fig. 2.20 Orbital rim augmentation. Axial (a) and 3D (b)

CT images in a patient with dysthyroid orbitopathy show
that hardware below the bilateral inferior orbital rims was
used to secure a porous polyethylene implant (not visible
on these images)
2.6 Dacryocystorhinostomy via a dacryocystogram (Fig. 2.21). Surgical suc-

and Nasolacrimal Duct cess rates are high with reports mostly ranging in
Stents the 90% and above.
In cases of proximal lacrimal stenosis
2.6.1 Discussion involving the canaliculi, conjunctivodacryocys-
torhinostomy (CDCR) can be performed. This
Dacryocystorhinostomy (DCR) can be performed procedure involves the placement of a Jones
to relieve distal lacrimal obstruction at the level tube, which is a direct bypass from the ocular
of the lacrimal sac or duct. Both external and surface to the middle meatus of the nose
endonasal approaches can be used to remove (Fig. 2.22). These Pyrex glass tubes are readily
bone in the region of the medial canthus in order depicted on CT, which can be used effectively
to create a fistula between the nasolacrimal sac to assess for complications, such as malposi-
and the medial meatus of the nasal cavity. tion, migration, or inflammation of surrounding
Silicone tubes are usually temporarily inserted tissues. An uncommon complication of Jones
through this fistula to ensure prolonged patency. tube placement is pneumo-orbit, which can
Postoperative complications occur in about 6% occur after CPAP use, sneezing, or nose blow-
of cases and most commonly include restenosis ing, and can result in proptosis if a significant
with recurrent epiphora or dacryocystitis. Patency amount of air is forced through the tube
of the dacryocystorhinostomy can be evaluated (Fig. 2.23).
a b
Fig. 2.21 Dacryocystorhinostomy. Axial (a) and coronal CT (d) images from a left dacryocystogram verify free
(b) CT images show an osteotomy predominantly through spillage of contrast into the ethmoid air cells/nasal cavity
the anterior lacrimal crest of the left maxilla (arrows) after (arrowheads)
external dacryocystorhinostomy. Radiograph (c) and axial
c d
Fig. 2.23 Pneumo-orbit with Jones tube. The patient had

Fig. 2.22 Conjunctivodacryocystorhinostomy (CDCR) a history of CDCR with Jones tube placement and pre-
with Jones tube. Coronal CT image shows a left CDCR sented with proptosis after sneezing. Coronal CT image
with a Pyrex glass Jones tube in position (arrow). The tube shows a Jones tube (arrow) and extensive air within the
connects the ocular surface with the middle meatus of the left orbit
nose. In this case, it is somewhat medially displaced
2.7 Strabismus Surgery The effects of rectus transposition can be appre-

ciated on imaging, including changes in size as
2.7.1 Discussion morphology of the rectus muscles and signal
alterations on MRI. Although improved ocular
Strabismus secondary to cranial nerve palsy can alignment can also be noted on imaging, this is
be treated by rectus muscle transposition. Several readily assessed on clinical exam. Nevertheless,
techniques can be performed, including reposi- imaging can be useful for evaluating postopera-
tioning portions of the rectus muscle bellies onto tive complications, such as rectus muscle rupture
the sclera, with or without tenotomy (Fig. 2.24). (Fig. 2.25) and infection (Fig. 2.26).
Fig. 2.24 Y splitting of the lateral rectus with medial

transposition. Coronal T1-weighted MR image shows
splitting and thickening of the bilateral lateral rectus mus-
cle bellies (arrows)
a b
Fig. 2.25 Postoperative rectus muscle rupture. The an abrupt caliber change and signal abnormality in the
patient presented with recurrent right exotropia after bilat- belly of the right medial rectus muscle (arrow). The distal
eral medial rectus resections. The right medial rectus portion of the right medial rectus is lax, and there is lateral
muscle was noted to be friable intraoperatively. Axial rotation of the globe. Bilateral lens implants are also
T2-weighted (a) and T1-weighted (b) MR images show present
a b
Fig. 2.26 Postoperative abscess. The patient presented with edema and erythema around the left eye after strabismus
surgery. Axial (a) and coronal (b) CT images show a left periorbital rim-enhancing fluid collection
2.8 Glaucoma Surgery a

2.8.1 Discussion
Glaucoma shunts and valves are surgically

implanted devices that reduce intraocular pres-
sure by decompression of aqueous humor.
Several types of implants are commercially
available, including the Ahmed, Baerveldt,
Krupin, and Molteno. The Molteno and Baerveldt
devices are non-valved devices (Fig. 2.27), while
the Krupin and Ahmed devices include valves
(Fig. 2.28). The basic design of a valved shunt b
consists of a tube drain, valve, and footplate
(Fig. 2.29). The one-way valve closes below a
certain intraocular pressure, thereby preventing
hypotonia of the globe. End plates with larger
surface area have greater ability to dissipate the
aqueous humor. The devices are usually
implanted superotemporal to the globe, with end
plate positioned against the scleral surface and
the fine tube drain inserted into the anterior
chamber. However, the device can also function
in the inferotemporal or superomedial quadrant
and can drain into the paranasal sinuses
(Fig. 2.30). A fibrous capsule forms around the
end plate, eventually forming a reservoir or bleb.
The fluid is normally resorbed by the surround-
Fig. 2.27 Baerveldt shunt. Axial (a) and coronal (b) CT
ing tissues, such that there is no significant accu-
images demonstrate the hyperattenuating device (arrows)
mulation. Glaucoma valve shunts often contain positioned superolateral to the globe. Several radiolucent
radiopaque barium-impregnated silicone. Ahmed valves are also present within the bilateral orbits
Alternatively, these devices can be composed of
polypropylene, which is of intermediate attenua-
tion on CT. Glaucoma valve implants are MRI
compatible and appear as low signal on both T1-
and T2-weighted sequences surrounded by a
small amount of fluid in the reservoir.
Complications include hypotonia, malposition,
tube obstruction, and giant bleb formation
(Fig. 2.31), secondary to adhesions between
Tenon’s capsule and the episcleral space, infec-
tion (Fig. 2.32), and choroidal detachment
(Fig. 2.33). Newer non-tube implants, such as
the Ex-PRESS shunt, do not require iridotomy
and result in less postoperative inflammation.
The Ex-PRESS shunt is a non-valved stainless
steel implant that is inserted under a scleral flap
in a paralimbal site (Fig. 2.34).
Fig. 2.30 Glaucoma valve drainage into maxillary sinus.

Fig. 2.28 Ahmed valve. Axial CT image shows the Coronal CT image shows a radiopaque Ahmed valve posi-
valved device (arrow) positioned alongside the left globe tioned inferior to the left globe (arrow), where it drains
into the maxillary sinus. There are also superolateral and
superomedial radiolucent Ahmed valves (arrowheads)
Fig. 2.29 Photo of a glaucoma valve device during sur-

gery. The components include the valve on the footplate
(arrowhead) and tube (arrow) (Courtesy of Fatoumata
Yanoga MD)
a b
Fig. 2.31 Glaucoma tube shunt-related blebs. Coronal Ahmed valves surrounded by minimal fluid on the right
(a) CT image shows a large fluid collection (arrow) and a larger amount fluid on the left (arrow), which
around the radiolucent inferolateral Ahmed valve. Coronal indents the globe
T2-weighted MRI (b) shows bilateral linear low-signal
Fig. 2.33 Hemorrhagic suprachoroidal detachments fol-

lowing glaucoma valve implantation. Axial CT image
shows a suprachoroidal hemorrhage within the left globe.
A radiolucent Ahmed valve is present temporally and
there is preseptal edema
Fig. 2.32 Orbital cellulitis after Ahmed valve implanta-

tion. Axial (a) and coronal (b) CT images show pre- and
postseptal inflammatory changes surrounding the device
in the superolateral left orbit
a b
Fig. 2.34 Ex-PRESS glaucoma shunt. Axial (a) and coronal (b) CT images show a punctate metallic structure in the
region of the anterior chamber of the left globe (arrows). Photograph of the device (c) (Courtesy of Alcon/Novartis)
2.9 Scleral Buckles tion that may lead to diagnostic imaging is infec-
tion, which can manifest as stranding and
2.9.1 Discussion enhancement of the orbital fat surrounding the
device and thickening of the sclera, with or with-
Scleral buckles partly or completely encircle the out fluid collections from abscess formation
globe for the treatment of retinal detachment. (Fig. 2.39).
The buckles work by exerting pressure in order to Although less stiff and prone to causing scleral
appose the layers of the retina together. These erosion than silicone implants, hydrogel (Miragel)
devices are composed of either hydrophilic scleral buckles are permeable to water and there-
hydrogel polymers or silicone, which in turn are fore can gradually swell over years or decades. On
available in the form of solid rubber bands or MRI, the fluid consistency of the hydrated implant
sponges, or a combination of these (Figs. 2.35, is evident as high T2 signal and low T1 signal
2.36, and 2.37). On CT, silicone rubber bands are (Fig. 2.40). There may be rim enhancement, as a
of high density, while the sponges are nearly air fibrous capsule often forms around these buckles.
attenuation. On MRI, the silicone scleral buckles Dystrophic calcifications can appear as curvilinear
are of low signal intensity on both T1- and or punctate densities along the edges of the implant.
T2-weighted sequences. Mild circumferential Thus, the imaging appearances of this process may
indentation of the globe is an expected finding. In mimic an orbital mass or infection. However,
the past, small clips composed of tantalum were available past surgical history, the tubular configu-
used to secure the free ends of the buckles ration of the implant encircling the globe, and lack
(Fig. 2.38). The tantalum clips are MRI compat- of restricted diffusion should lead to the proper
ible. Scleral buckles should not be confused with diagnosis. Due to brittle nature of the hydrated
calcifications, hemorrhage, or masses. The main hydrogel scleral buckles, they have a tendency to
complication related to scleral buckle implanta- fragment and become displaced (Fig. 2.41).
a b
Fig. 2.35 Silicone rubber encircling buckle. Axial (a) of very low signal intensity on MRI (c), with expected
and coronal (b) CT images show a high-attenuation band indentation of the globe
surrounding the right globe. The scleral band (arrows) is
c a
Fig. 2.36 Silicone sponge scleral buckle. Axial (a) and

coronal (b) CT images show a low-attenuation sclera
buckle surrounding the left globe. There is also silicone
oil in the left globe
a b
Fig. 2.37 Combined silicone rubber band and sponge. Axial (a) and coronal (b) CT images show hyperattenuating and
hypoattenuating components of the left scleral buckle
a b
Fig. 2.38 Scleral buckle with tantalum clip. Axial (a) and coronal (b) CT images show a small metallic clip (arrows)
adjacent to the globe
a b
Fig. 2.39 Infected scleral buckle. Axial (a) and coronal (b) CT images show pre- and postseptal inflammatory changes
of the right globe surrounding the scleral buckle. In addition, there is scleritis and a subchoroidal effusion
a b
Fig. 2.40 Hydrogel scleral buckle hydration and expan- tions. Axial T2-weighted (b) and axial T1-weighted (c)
sion. Axial CT image (a) shows circumferential enlarge- MRI sequences show that the enlarged right scleral buckle
ment of the right hydrogel scleral buckle (arrows), which contains fluid signal (arrows)
has fluid attenuation. There are also partial rim calcifica-
a b
Fig. 2.41 Hydrogel scleral buckle hydration, fragmenta- scleral buckle (arrows) has migrated into the superotem-
tion, and migration. Axial (a) and sagittal (b) CT images poral quadrant of the left orbit, where it indents the globe
show that the unraveled, hydrated, and partially calcified
2.10 Keratoprostheses device composed of a polymethyl methacrylate

(PMMA) front plate and its stem and a PMMA or
2.10.1 Discussion titanium back plate, while the type II device has an
additional anterior nub that allows for through-the-
Keratoprostheses are artificial corneal substitution lid implantation (Fig. 2.42). The devices are con-
devices. The Boston keratoprostheses are perhaps sidered MRI compatible. Complications that can
the most commonly used and are available in two be observed on CT or MRI include inclusion cyst
forms: the type I device is a collar button-shaped formation and vitreous hemorrhage.
a b
Fig. 2.42 Keratoprostheses. Axial CT image (a) shows a the right side (arrow). Photograph of a Kpro device in situ
Kpro type 1 device on the left and a Kpro type II device on (b) (Courtesy of Kathryn Colby MD)
the right. A glaucoma drainage device is also present on
2.11 Intraocular Lens Implants a
2.11.1 Discussion
Cataract is a common cause of reversible vision

loss and can be treated via cataract extraction
and intraocular lens implantation when symp-
tomatic. Intraocular lens implants consist of two
main components: the optic and two haptics.
These lens implants can be composed of poly-
methylmethacrylate, silicone, hydrogel, poly-
ethylene, polypropylene, or a combination of
these. The lens implants may be positioned pos-
terior or anterior with respect to the plane of the
iris. Unlike native lenses, lens prostheses are
very thin structures in profile, as seen on an
axial image. The optic appears as hyperattenuat-
ing on CT and is of low signal intensity on both b
T1- and T2-weighted MRI sequences (Fig. 2.43).
The haptics are not readily visible at 1.5 T or on
thin-section CT. Intraocular lens implants do
not normally enhance. Complications of cata-
ract surgery with intraocular lens implants
include retained lens fragments, implant dislo-
cation, and less commonly dystrophic calcifica-
tions. Implant dislocation can result from
inadequate capsular or zonular support or fol-
lowing traumatic injury. While some of these
complications may be apparent on CT and MRI
(Figs. 2.44 and 2.45), ophthalmic ultrasound is
generally the modality of choice, but is beyond
the scope of this text.
c
Fig. 2.43 Posterior chamber intraocular lens (IOL)

implant following cataract surgery. Sagittal CT (a) and
T2-weighted MRI (b) show a left posterior chamber
intraocular lens Photograph of a standard IOL implant (c)
(Courtesy of Hoopes Vision)
Fig. 2.45 Intraocular lens implant dystrophic calcifica-

Fig. 2.44 Intraocular lens implant dislocation. Axial T2 tion. Axial CT image shows irregular clumps of calcifica-
MRI shows the posteriorly displaced left lens implant tion deposited on the surface of the left lens implant
(arrow) (arrow)
2.12 Surgical Aphakia 2.13 Pneumatic Retinopexy
2.12.1 Discussion 2.13.1 Discussion
Historically, cataract surgery was initially per- Intraocular gas injection is a technique used to
formed without placement of an intraocular lens tamponade the retina during retinal detachment
implant. In the modern era, utilizing small inci- surgery until chorioretinal adhesions form (pneu-
sion cataract surgery, a variety of implantable matic retinopexy). The procedure is effective for
lenses are in common use. However, in certain treating retinal detachment in up to 80% of cases.
situations, the implantation of an intraocular lens Intraocular gas injection can also be used to
after cataract surgery is still not undertaken. For restore intraocular volume during scleral buckle
example, the placement of intraocular lenses in surgery. A variety of gases can be used, including
very small children has been controversial over air, sulfur hexafluoride, and perfluoropropane.
the years, and some children are left aphakic after On CT, air lucency is present antidependently in
surgery. On imaging, there is no apparent separa- the vitreous body, creating an air-fluid level
tion between the anterior and posterior chambers (Fig. 2.47). Complications of intraocular air
of the globe (Fig. 2.46). injection include secondary glaucoma, subretinal
gas or anterior chamber migration, vitreous hem-
orrhage, new retinal breaks, endophthalmitis, and
delayed reabsorption of subretinal fluid.
Fig. 2.47 Pneumatic retinopexy. Axial CT image demon-

strates intravitreal gas on the right side
Fig. 2.46 Surgical aphakia. Axial T2-weighted MRI

shows absence of the left lens
2.14 Intraocular Silicone Oil Fat saturation pulses can also cause some degree
of signal suppression, also differentiating it from
2.14.1 Discussion hemorrhage. The silicone oil used for tamponade
is often surgically removed after placement, but
Intravitreal silicone oil placement is sometimes may remain permanently, depending on the risk
used in cases of intractable retinal detachment. of recurrent detachment. Complications of sili-
The silicone oil is visible on CT and MR imaging cone oil retinopexy include choroidal detach-
(Fig. 2.48). On CT, silicone oil is hyperattenuat- ment, retinal re-detachment, glaucoma, migration
ing, measuring up to 120 HU, but floats. On MRI, to the anterior chamber with corneal endothelial
silicone oil tends to be hyperintense to water on damage, and cataract formation. In very rare
T1-weighted sequences and hypointense to water instances, intracranial migration of silicone oil
on T2-weighted sequences. Chemical shift arti- can occur via the optic nerve and into the ven-
fact at the interface between the silicone oil and tricular system via the subarachnoid space in
fluid can be used to distinguish the two entities. optic nerve sheath (Fig. 2.49).
a b
c d
Fig. 2.48 Intraocular silicone oil. Axial CT image (a) cone. Chemical shift artifact is present at the interface
shows globular high-attenuation material floating within between the silicone and the vitreous and loses signal with
the posterior chamber of the left globe. T2-weighted MRI fat suppression (d)
(b) and T1-weighted MRI (c) showing the intraocular sili-
Fig. 2.49 Intraventricular silicone oil migration. Axial

CT image shows the hyperattenuating silicone oil floating
within the bilateral frontal horns of the lateral ventricles
(arrows) (Courtesy of Bruno Policeni MD)
2.15 Evisceration, Enucleation, including hollow glass spheres (Fig. 2.50).

and Globe Prostheses Currently, hydroxyapatite, solid silicone, and
porous polyethylene prostheses are most com-
2.15.1 Discussion monly used. These prostheses have distinct fea-
tures on imaging (Figs. 2.51, 2.52, and 2.53).
Evisceration consists of removing the globe con- Diffuse linear enhancement surrounding the
tents while preserving the sclera and extraocular implant components is frequently present on
muscles, while enucleation consists of removing MRI and is of no clinical significance.
the globe entirely along with the anterior portion Occasionally, the scleral cover shell prosthesis is
of the optic nerve. These procedures are mainly used alone if orbital volume is adequate
performed for intraocular malignancies and (Fig. 2.54). Since the orbital implant volumes are
irreparable globe rupture. Following enucleation, virtually always smaller than the normal globe,
globe implants are often used to provide orbital various materials have been used as support
volume and cosmetic effect. Although a wide materials for the orbital prosthesis, including sili-
variety of globe implant designs are available, the cone blocks and glass beads (Figs. 2.55 and
typical globe implant has two components: a 2.56), and are generally located in the extraconal
deep spherical orbital implant, which can be space. Complications related to orbital implants
placed within the remaining sclera, and an ante- are uncommon, but include rotation, infection,
rior scleral cover shell prosthesis, somewhat inflammation, and exposure (Figs. 2.57 and
analogous to a large contact lens in terms of 2.58). Imaging is complimentary to physical
shape and location. In the past, a wide variety of examination for evaluating some of these
metallic implants were used in globe prostheses, complications.
Fig. 2.51 Hydroxyapatite implant. Axial CT image

Fig. 2.50 Hollow glass globe implant. Axial CT image shows a hyperattenuating left globe implant with a charac-
(a) shows an air-filled right orbital implant teristic cobblestone pattern
a b
Fig. 2.52 Silicone implant. Axial T2-weighted (a) and T1-weighted (b) MR images show a markedly hypointense
implant in the right orbit
a b
c
d
Fig. 2.53 Porous polyethylene implant. Axial CT image different patient show that the left globe implant has
(a) shows that the left globe implant has a density between relatively low T1 and T2 signal, but enhances due to
that of fluid and fat. Axial T2-weighted (b), T1-weighted fibrovascular ingrowth
(c), and post-contrast T1-weighted (d) MR images in a
Fig. 2.54 Scleral cover shell prosthesis. Axial CT image

shows a right scleral cover shell prosthesis used without
orbital augmentation following enucleation
Fig. 2.56 Orbital augmentation with silicone implant.

Sagittal CT image shows a hyperattenuating silicone
implant (arrow) beneath a hollow prosthesis
Fig. 2.55 Orbital augmentation beads. Axial CT image

shows multiple hyperattenuating beads in the right orbit,
where enucleation has been performed
a b
Fig. 2.57 Globe implant rotation. Axial CT image (a) oriented medially, compared with the normal configura-
shows a gap between the rectus muscles and the implant, tion of the implant in a different patient (b)
which is rotated 90°, such that the metal mesh (arrow) is
a b
Fig. 2.58 Globe implant exposure. The patient had a his- tal (b) CT images show infiltration of the left orbital fat
tory of enucleation approximately 40 years prior to pre- and soft tissue surrounding the prosthesis, which proved
sentation with discomfort and discharge from the left to be granulation and scar tissue at subsequent surgery.
orbit. Physical examination revealed an extruding orbital The inferior portion of the implant is angled anteriorly,
implant, but no evidence of infection. Axial (a) and sagit- and the scleral cover shell prosthesis is absent
2.16 Orbital Tissue Expanders and volume of the expanders can be evaluated via
CT or MRI. Hydrogel expanders appear as either
2.16.1 Discussion spherical or hemispherical structures with nearly
fluid attenuation on CT and low T1 and high T2
Orbital tissue expanders are implanted devices MRI signal intensity and do not enhance
used for enlarging the orbital cavity in patients (Fig. 2.59). Saline expanders appear as spherical
with congenital anophthalmia and microphthalmia fluid-density structures on CT adjacent to the
and can obviate surgery. The main types of orbital metal-density T-plate. The saline expanders have
expanders include hydrophilic osmotic hydrogel similar imaging characteristics as the aqueous on
devices or inflatable saline globes. The placement CT and MRI and are attached to metallic T-plate.
Fig. 2.59 Hemispheric hydrogel expander. Axial

T2-weighted (a) and T1-weighted (b) MR images show
bilateral orbital implants with similar signal characteris-
tics as fluid. Photograph of the hydrogel hemispheric
implants when dry and hydrated (c) (Courtesy of Osmed)
2.17 Orbital Exenteration with removal of structures surrounding the orbit,

such as paranasal sinuses and skull base
2.17.1 Discussion (Figs. 2.60, 2.61, 2.62, and 2.63). The socket cre-
ated by more extensive exenteration procedures
Orbital exenteration is performed for treatment of can either heal by granulation or lined with skin
primary orbital malignancies and periorbital graft or tissue flap. Since patients who undergo
malignancies that invade the orbit. Several types exenterations for malignant neoplasms typically
of orbital exenteration procedures can be per- receive radiation therapy, complications may
formed with various degrees of dissection, rang- include necrosis (Fig. 2.64), infection, tumor
ing from extended enucleation, subtotal recurrence (Fig. 2.65), and radiation-induced
exenteration with sparing of the eyelid, total neoplasms (Fig. 2.66), which can occur many
exenteration with removal of the eyelid in addi- years after treatment.
tion to orbital contents, and radical exenteration
Fig. 2.60 Orbital exenteration and facial implant. The

patient had a remote history of advanced retinoblastoma
treated with orbital exenteration and radiation. Axial CT
image shows resection of the left orbit and reconstruction
via silicone implant (arrow), with surrounding dystrophic
calcifications
a b
d
c
Fig. 2.61 Orbital exenteration with maxillectomy and graft is derived from the left facial artery and vein. Sagittal
flap reconstruction. The patient has a history of recurrent (b) T1-weighted, axial T2-weighted (c), and fat-sup-
stage IV left face squamous cell carcinoma treated with pressed coronal contrast-enhanced T1-weighted (d) MRI
radical exenteration with myocutaneous flap reconstruc- sequences show the subcutaneous fat (F) portion of the
tion in addition to chemoradiation. Axial CT image (a) graft, which loses signal with fat suppression. There is
shows the normal-appearing muscle (M) and fat (F) com- normal enhancement of the muscle component of the graft
ponents of the myocutaneous thigh flap within the left (M), which suggests viability
orbit and maxillectomy defect. The vascular supply to the
Fig. 2.63 Orbital exenteration with implant. The patient

has a history of left ocular melanoma with extrascleral
extension. Axial contrast-enhanced T1-weightwed MR
images demonstrate a left orbital exenteration and recon-
struction using an orbital implant
Fig. 2.64 Graft necrosis. Axial CT image shows right

orbital exenteration. Sheets of air are present within the
shrunken myocutaneous flap
Fig. 2.62 Radical orbital exenteration. The patient has a his-

tory of squamous cell carcinoma involving the left orbit and
treated with radical orbital exenteration. Recent postopera-
tive axial CT image (a) shows left radical orbital exentera-
tion with bone flap reconstruction of the orbital floor and
surgical packing (P). Coronal CT (b) and post-contrast
T1-weighted MRI (c) shows bifrontal craniotomies, an air-
filled left orbit that communicates with the nasal cavity (*),
and a denuded orbital roof (arrows), which was allowed to
heal via granulation
Fig. 2.65 Tumor recurrence. The patient has a history of

exenteration of the left orbit for squamous cell carcinoma. Fig. 2.66 Radiation-induced osteosarcoma. Axial fat-
Axial CT image shows a nodular lesion in the medial suppressed post-contrast T1-weighted MRI shows a het-
aspect of the left orbit (arrow) erogeneously enhancing mass (arrow) arising medal to
the right orbit, which contains an ocular implant and
prosthesis
2.18 Orbital Radiation Therapy orbital radiation therapy fiducial markers are
Fiducial Markers initially surgically sutured to the globe for
tumor localization during treatment. The mark-
2.18.1 Discussion ers may be incidentally encountered on CT as
tiny metallic structures along the surface of the
Stereotactic radiosurgery can be used to treat a globe (Fig. 2.67) and are compatible with MRI
variety of ocular tumors. Small tantalum ring at 1.5 T.
Fig. 2.67 Tantalum rings. Axial (a) CT image shows

three metallic markers along the surface of the left globe.
Photograph of a tantalum ring (b) (Courtesy of Altomed)
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Imaging the Paranasal Sinuses
and Nasal Cavity 3
Daniel Thomas Ginat, Mary Elizabeth Cunnane,
and Robert M. Naclerio
3.1 asal Fracture Reconstruction

N reconstruct substantial defects (Fig. 3.1). Low-
(Posttraumatic Rhinoplasty) profile mesh material provides fracture fixation
with good cosmetic results (Fig. 3.2). Likewise,
3.1.1 Discussion temporary external plates and transcutaneous wire
can help restore satisfactory alignment. Nasal
The aim of posttraumatic rhinoplasty surgery is to stents are sometimes inserted to maintain patent
restore the pretraumatic state and normal function nasal passages, while the fracture and associated
and appearance of the nose. The surgical technique soft tissue injury heal. CT is generally the imaging
depends on the degree of comminution, associated modality of choice for postoperative traumatic rhi-
septal fracture, and presence of other facial frac- noplasty assessment. Low-radiation dose tech-
tures. Internal and external fixation approaches can niques are typically adequate. Cosmetic rhinoplasty
be implemented. Bone grafting can be used to is otherwise discussed in Chap. 1.

Department of Radiology, University of Chicago
M.E. Cunnane, M.D.
Department of Radiology, Harvard Medical School,
Massachusetts Eye and Ear Infirmary,
Boston, MA, USA
R.M. Naclerio, M.D.
Section of Otolaryngology-Head and Neck Surgery,
University of Chicago Pritzker School of Medicine,
Chicago, IL, USA

DOI 10.1007/978-3-319-52341-5_3
Fig. 3.2 Nasal fracture reconstruction with low-profile

mesh. 3D CT image shows a mesh positioned along the
Fig. 3.1 Cortical bone reconstruction. 3D CT image nasal dorsum secured via low-profile screws. There are
shows cortical bone graft positioned along the expected also bilateral molded polyvinyl siloxane plates (arrows)
site of the nasal dorsum (arrow) and absence of the native fit over the nasal soft tissue in the medial canthal area and
nasal bones and frontal processes of the maxilla secured via transcutaneous wires
3 Imaging the Paranasal Sinuses and Nasal Cavity 77
3.2 Septoplasty both sides of the nasal septum to prevent the for-
mation of adhesions (Fig. 3.4). These are later
3.2.1 Discussion removed once the surgical site heals. The postop-
erative imaging appearance often consists of a
Septoplasty is performed to treat a deviated nasal straightened and thinned nasal septum with wid-
septum and can be performed in conjunction with ened nasal passages, which can be subtle.
rhinoplasty (septorhinoplasty). Classic septo- Complications are uncommon and include hem-
plasty consists of creating a mucoperichondrial orrhage, cerebrospinal fluid leak, infection, sep-
flap in order to remove the offending portion of tal hematoma or abscess, overcorrected septum,
the nasal septum via sharp dissection (Fig. 3.3). septal perforation (Fig. 3.5), adhesions, and sen-
Silastic sheets or stents are often inserted along sory disturbances.
a b
Fig. 3.3 Septoplasty. The patient has a history of a devi- 1 year after surgery (b) shows interval removal of the spur
ated nasal septum with spur causing nasal obstruction. and straightening of the nasal septum. There is also
Preoperative axial CT image (a) shows leftward deviation increased opacification of the left maxillary sinus
of the nasal septum with a spur. Axial CT image obtained
3.3 asal Septal Button

N
Prosthesis
3.3.1 Discussion
Nasal septal perforation may present with vari-

ous symptoms: epistaxis, crusting, secondary
infection, whistling, and nasal obstruction.
Perforation can be treated by conservative phar-
macological treatment or by surgical closure.
Alternatively, a nasal septal button, often com-
posed of silicone, can be inserted transnasally to
span the perforation (Fig. 3.6).
Fig. 3.4 Nasal stents. The patient has a history of nasal

septal deviation and adhesions treated via septoplasty and
lysis of adhesions. Coronal CT image shows a straight,
midline septum flanked by bilateral nasal stents (arrows)
Fig. 3.6 Nasal septal button prosthesis. Axial CT image

shows the two discs connected to one another across the
nasal septal defect (arrow)
Fig. 3.5 Septoplasty perforation. Axial CT image shows

a defect in the anterior nasal septum. The septum is other-
wise straight. However, there is acute sinusitis
3.4 Inferior Turbinate coagulates the inferior turbinate submucosa.

Outfracture and Reduction This results in a widened nasal airway passage.
The procedures are often performed in conjunc-
3.4.1 Discussion tion with septoplasty. Lateral displacement of
the anterior, middle, and posterior portions is
Inferior turbinate outfracture and reduction are usually apparent on postoperative sinus CT
treatment options for nasal obstruction related (Fig. 3.7). Alternatively, turbinate reduction sur-
to inferior turbinate hypertrophy. Outfracture gery typically results in a truncated appearance
consists of laterally displacing the inferior
of the inferior turbinates and enlargement of the
turbinates, while radio-frequency treatment
nasal passages (Fig. 3.8).
Fig 3.8 Inferior turbinate reduction. Coronal CT image

b shows truncation of the inferior portions of the bilateral
inferior turbinates. Findings related to endoscopic sinus
surgery are also apparent
Fig. 3.7 Inferior turbinate outfracture. Axial (a) and cor-

onal (b) CT images show lateral deviation of the bilateral
inferior turbinates with reduced mucosa and evidence of
septoplasty, which result in a widened nasal passage
3.5 Nasal Packing Material have a tendency to imbibe blood products in the
early perioperative period, which is reflected in
3.5.1 Discussion the appearance on imaging (Fig. 3.9). Bismuth
and iodoform paraffin paste using some packing
Nasal packs are routinely used in sinonasal sur- material displays high CT attenuation that results
gery in order to apply pressure, fill preformed in severe image degradation. Aqueous Betadine
spaces, create moist environments to facilitate gauze also displays high attenuation on
physiological processes, function as a barrier, CT. Myospherulosis, a foreign body-type granu-
and induce physiological hemostatic and repara- lomatous reaction to lipid-containing material,
tive processes. Nasal packings, including has a characteristic fat-attenuation appearance
Merocel and MeroGel packs, and alginate strips on CT.
a b
c
d
Fig. 3.9 Nasal packing. Coronal CT image (a) shows T1-weighted (c) and fat-suppressed post-contrast
opacification of the right nasal cavity and paranasal T1-weighted (d) MR images show that the nasal packing
sinuses. Coronal T1-weighted MRI (b) shows that the (arrows) is mildly T1 hyperintense and does not enhance,
nasal packing material is very hypointense (arrow). The unlike the surrounding mucosa
3.6 Rhinectomy Prosthetic rehabilitation can be an alternative to flap

reconstruction, particularly in those patients unsuit-
3.6.1 Discussion able for major reconstruction. Customized prosthe-
ses can be created via computer-aided design based
Rhinectomy is an oncological procedure that on preoperative virtual laser scanning or CT of the
involves resecting part or all of the external nose affected site adapted to the postoperative laser-
when involved by high-risk nasal malignancies. scanned surface or CT (Fig. 3.10).
a b
Fig. 3.10 Total rhinectomy with nose prosthesis. The r hinectomy defect that was reconstructed using a custom-
patient had a history of nasal squamous cell carcinoma. made silicone prosthesis (arrows)
Axial (a) and sagittal (b) CT images show a total
3.7 Sinus Lift Procedure dome-shaped configuration on coronal images

(Fig. 3.11). The bone graft initially has a porous
3.7.1 Discussion appearance but consolidates with a more uni-
formly hyperattenuating appearance on CT as
The sinus lift or augmentation procedure is per- osseointegration and osteogenesis ensure after
formed to build up a deficient maxillary alveolus 6–8 months. Disruption of the sinus mucosa may
for subsequent osseointegrated dental implant result in sinusitis, graft infection, or formation of
insertion. The procedure involves accessing the oroantral fistula, which is best depicted on coro-
maxillary sinus and elevating the mucous mem- nal plane CT images (Fig. 3.12). Furthermore,
brane at the inferior aspect of the maxillary to graft material scattered in the sinus may also
create a space in the floor of the sinus where indicate surgical failure.
bone graft material is inserted, typically with a
Fig. 3.11 Sinus lift procedure. Coronal CT image shows

bone graft material (arrows) within the inferior maxillary
sinuses adjacent to the alveolar ridge. There are bilateral
osseointegrated implants
a b
Fig. 3.12 Sinusitis and oroantral fistula after sinus lift proof the right maxillary sinus. Follow-up CT image (b) shows
cedure. Coronal CT image (a) shows bilateral sinus lift a defect in the maxillary sinus floor (arrow) and persistent
procedures with osseointegrated implants and opacification right-sided sinus opacification
3.8 Caldwell-Luc Procedure Historically, the Caldwell-Luc procedure was

the primary sinus surgery until it was largely sup-
3.8.1 Discussion planted by functional endoscopic sinus surgery.
The Caldwell-Luc procedure has fallen out of
The Caldwell-Luc procedure was described by favor since it interrupts the ciliary clearance
Caldwell in 1893, Spicer in 1894, and Luc in mechanism of the maxillary sinus mucosa. As a
1897 for the treatment of maxillary sinusitis. The result, the procedure often exacerbates the condi-
technique originally consisted of creating a tions that it is intended to treat. Indeed, on postop-
defect in the inferior aspect of the anterior max- erative imaging, inflammatory sinus disease,
illary wall via a canine fossa approach and sinus collapse, and sinus wall sclerosis (osteitis)
removing diseased mucosa from the maxillary are found in over 80%, over 90%, and up to 100%
sinus, combined with inferior or middle meatus of cases, respectively (Fig. 3.14). Currently, mod-
antrostomy, in order to facilitate gravitational ification of the Caldwell-Luc procedure is mainly
intranasal counterdrainage and antral lavage reserved as an approach for resection of selected
(Fig. 3.13). maxillary sinus tumors and antrochoanal polyps.
Fig. 3.13 Caldwell-Luc surgery. Coronal CT image Fig. 3.14 Chronic recurrent sinusitis after bilateral
shows a defect in the left anterior maxillary sinus wall Caldwell-Luc surgery. Axial CT shows the bilateral post-
(arrowhead) and nasoantral wall (arrow) operative changes with mucosal thickening and hyperos-
tosis of the remaining maxillary sinus walls
3.9 External Ethmoidectomy 3.10 F

unctional Endoscopic Sinus
Surgery
3.9.1 Discussion
3.10.1 Discussion
In the past, before the advent of functional endo-
scopic surgery techniques, resection of the eth- Functional endoscopic sinus surgery (FESS) is
moid labyrinth was commonly performed for the used to treat chronic sinusitis and is occasionally
treatment of sinusitis via a transorbital approach. performed as part of tumor resection. The objec-
The lamina can also be removed endoscopically tive of FESS is to relieve obstruction of mucus
for tumors such as inverted papillomas. The sur- drainage while preserving the mucociliary clear-
gery involves resection of the ipsilateral lamina ance mechanism. The procedure consists of
papyracea through which the paranasal sinuses resecting various portions of the paranasal
can be visualized and accessed. The resulting sinuses using an intranasal endoscope depending
defect in the lamina papyracea can be substantial on the extent of disease and whether the anterior
(Fig. 3.15). Although external ethmoidectomy or posterior drainage routes are predominantly
has been largely supplanted by FESS for treating affected. The resulting changes are not necessar-
rhinosinusitis, the approach may still be imple- ily symmetric from right to left or reproducible
mented for resecting certain sinonasal tumors. from one patient to another. Nevertheless, certain
fundamental strategies are generally imple-
mented, which are based on the major mucosal
drainage pathways. CT with multiplanar
reformatted images is the first-line modality for
evaluating the paranasal sinuses and surrounding
structures following FESS.
Turbinoplasty or partial anterior middle turbi-
nectomy is sometimes performed in order to
increase the exposure of the paranasal sinuses.
The middle turbinate can be completely resected
if it is responsible for obstructing the middle
meatus (Fig. 3.16).
Uncinectomy is essentially performed dur-
ing all types of FESS when the ostiomeatal
complex is affected by rhinosinusitis, along
with resection of variable amounts of the ante-
Fig. 3.15 External ethmoidectomy. Coronal CT image rior ethmoid air cells. Since the anterior eth-
shows a defect in the right lamina papyracea (arrow), moid air cells normally comprise two-thirds to
through which the right ethmoid air cells were resected.
There is also right frontal blockage, which can be a com- three-quarters of the ethmoid air cells, the
plication of this approach resection cavity can extend rather far
posteriorly. Typically, anterior ethmoidecto- Draf type I through III based on the extent of
mies and uncinectomies are performed together agger nasi and frontal air cells resected
in order to optimally decompress the ostiome- (Figs. 3.19, 3.20, 3.21, and 3.22). The Draf type
atal complex and access the maxillary sinuses III (modified Lothrop) procedure is the most rad-
(Fig. 3.17). ical form of frontal sinusotomy and involves
Disease of the posterior drainage system can resection of the upper internasal septum in addi-
be treated via ethmoidectomy alone or in com- tion to the frontal air cells.
bination with sphenoidotomy, which consists of Occasionally, a defect is created in the medial
enlarging the sphenoid sinus ostium (Figs. 3.18 maxillary sinus wall (antrostomy or nasoantral
and 3.19). This is often performed in conjunc- window), although this is not considered a stan-
tion with decompression of the ostiomeatal dard part of FESS (Fig. 3.23). Another twist that
complex. is sometimes performed during FESS is
Disease that affects the frontoethmoid drain- Bolgerization, which consists of stripping away
age pathway can be addressed via frontal recess part of the mucosa of the nasal septum in order to
sinusotomy. Frontal recess sinusotomy secure a loose middle turbinate and prevent
approaches have been traditionally classified as lateralization.
Fig. 3.17 Typical pattern of ostiomeatal unit

FESS. Coronal CT image shows the absence of the bilat-
eral anterior ethmoid air cells and uncinate processes,
resulting in widely patent anterior drainage pathways and
Fig. 3.16 Middle turbinectomy. Coronal CT image clear sinuses
shows resection of the left middle turbinate, leaving
behind a portion of the left vertical lamella (arrow). There
is a concha bullosa on right side
a a
b
b
Fig. 3.18 Posterior drainage pathway FESS. Axial (a)

and sagittal (b) CT images show bilateral enlarged sphe-
noid ostia (arrows). Bilateral total ethmoidectomies and c
middle turbinectomies were also performed
Fig. 3.19 Illustration of the types of frontal sinusotomy.

Draf type I (a), Draf type II (b), and Draf type III (c)
a b
Fig. 3.20 Draf type I frontal sinusotomy. Preoperative (b) shows a defect in the inferior aspect of the right agger
coronal CT image (a) shows a partially opacified right nasi cell (arrow)
agger nasi cell (arrow). Postoperative coronal CT image
Fig. 3.21 Draf type II frontal sinusotomy. Coronal CT

image shows a complete absence of the air cells in the left
frontoethmoidal sinus drainage pathway, as compared to
the intact contralateral side. Turbinate resection was also
performed
3.11 FESS Complications
3.11.1 Discussion
Surgical packing material, such as gauze, may

sometimes be left temporarily in the sinuses after
functional endoscopic surgery for hemostasis. In
the early postoperative period, the gauze can
appear as heterogeneous material often contain-
ing foci of trapped air, but over time the retained
gauze resembles a soft tissue mass with an atten-
uation of approximately 50 HU on CT (Fig. 3.24).
Not all types of gauze packing contain radioat-
tenuating markers. Furthermore, the retained
packing may not show enhancement on CT or
MRI. Occasionally, patients may not return for
postsurgical follow-up, and the packing may
Fig. 3.22 Draf type III frontal sinusotomy (modified
Lothrop). Coronal CT image shows contiguous bilateral
remain for long periods of time, resulting in a
enlargement of the frontal sinus floors and resection of the gossypiboma. This may cause recurrence of sinus
interfrontal sinus septum and superior nasal septum. symptoms and may even predispose to infection.
Septoplasty was also performed with Silastic plates in However, resorbable packing materials have also
position
been developed that do not require removal.
Fig. 3.23 Nasoantral window. Coronal CT image shows Fig. 3.24 Retained surgical packing (gossypiboma). The
surgical defects in the bilateral medial maxillary antrum patient presents with headache after functional endo-
walls (arrows) in addition to bilateral partial scopic sinus surgery a couple of weeks before and
ethmoidectomies neglected to attend the routine postoperative appointment
to have the packing removed. Axial CT image shows
changes related to FESS and non-enhancing material that
contains foci of air filling the ethmoid sinuses (encircled)
3.11.2 Discussion presence of sinus opacification contiguous with

the intracranial compartment is suggestive, but
Cephaloceles and cerebrospinal fluid leaks are not specific for encephalocele or meningocele.
serious complications of endoscopic sinus sur- Rather, MRI is better suited for diagnosing
gery that can result from inadvertently creating meningoceles, encephaloceles, and associated
defects in the floor of the anterior cranial fossa. soft tissue injury (Fig. 3.26). Radionuclide cis-
On CT, the presence of pneumocephalus is a ternographic studies do not adequately localize
helpful indicator that there is indeed intracranial and characterize skull base defects well enough
penetration and cerebrospinal fluid leak to be the sole diagnostic examination. Rather,
(Fig. 3.25). High-resolution CT with multipla- radionuclide cisternography is reserved for
nar reconstructions is useful for evaluating complex cases when the diagnosis is in
the presence of bony dehiscence. However, the uncertain.
Fig. 3.25 Cerebrospinal fluid leak. The patient presented

with headache and rhinorrhea after FESS. Coronal CT
image shows left-sided pneumocephalus and a defect in the
left cribriform plate
a b
Fig. 3.26 Encephalocele and intraparenchymal hemor- brain tissue through the defect in the ethmoid roof. In
rhage. Coronal CT image (a) shows internal ethmoidecto- addition, there is high signal intensity in a linear distribu-
mies and dehiscence of the right ethmoid roof (arrow). tion (arrows), which corresponds to hemorrhage along the
There is nonspecific opacification inferior to the dehis- path of the misdirected surgical instrument
cence. Coronal (b) T1-weighted MRI shows herniation of
3.11.3 Discussion result from direct injury to orbital vessels, ethmoid

arteries, or extension into the orbit through a
Intraorbital complications related to FESS include medial wall defect and may cause an acute rise in
herniation of intraorbital contents through iatro- orbital pressure with rapid onset of proptosis and
genic defects in the lamina papyracea, orbital loss of vision. Orbital CT and MRI are both suit-
hemorrhage, optic nerve transection (Fig. 3.27), able modalities for evaluating orbital trauma
and orbital cellulitis. Intraorbital hemorrhage can related to FESS.
a b
Fig. 3.27 Orbital injury. The patient presented with left lamina papyracea, abundant pneumo-orbit, retrobulbar
vision loss after FESS. Coronal CT images in the bone (a) hemorrhage, and deformity of the optic nerve on the left
and soft tissue (b) windows show a large defect in the left side
3.11.4 Discussion retract into the orbit, resulting in intraorbital hem-

orrhage. High-resolution CT can accurately detect
Both extracranial and intracranial vessels can be the site of entry, which is usually via the fovea
injured during FESS. The anterior ethmoidal ethmoidalis or roof of the ethmoid sinus. Cerebral
arteries are particularly susceptible to laceration. angiography is recommended to locate an associ-
Although this can be treated by clipping during ated pseudoaneurysm, which can often be treated
the procedure (Fig. 3.28), the artery can potentially endovascularly (Fig. 3.29).
Fig. 3.28 Ethmoid artery injury. Coronal CT image

shows a vascular clip (arrow) in the region of the left ante-
rior ethmoid artery groove, which was applied to stop
bleeding from the injury artery. There is evidence of left-
sided internal ethmoidectomy with the presence of bony
defect within the left lamina papyracea
a b
Fig. 3.29 Anterior cerebral artery pseudoaneurysm. The intraparenchymal hemorrhage with a flame-shaped con-
patient presented with sudden-onset mental status figuration (arrow). Digital subtraction cerebral angio-
changes and headache a few days after undergoing pol- gram (b) reveals a pseudoaneurysm (arrow)
ypectomy. Axial CT image (a) shows left gyrus rectus
3.11.5 Discussion forces of contracture during the postoperative

healing period (Fig. 3.30). On average, the inter-
Medial bowing of the lamina papyracea can orbital distance decreases by about 1 mm after
occur following internal ethmoidectomy perhaps surgery and mild enophthalmos results. These
due to the loss of internal structural support and changes are usually subclinical.
a b
c
d
Fig. 3.30 Medialized lamina papyracea. Preoperative ethmoidectomies and middle turbinate with medial bow-
axial (a) and coronal (b) CT images show normal align- ing of the laminae papyracea. There is also new opacifica-
ment of the bilateral lamina papyracea. Postoperative tion of the ethmoid sinuses
axial (c) and coronal (d) CT images show bilateral internal
3.11.6 Discussion recurrent symptoms. Mucosal inflammation

and synechiae are often indistinguishable on
Mucosal inflammatory disease is common after imaging and may certainly coexist. However,
FESS (Fig. 3.31). Mucosal thickening up to synechiae can appear as thin bands of soft
3 mm is considered normal. However, the tissue within or adjacent to the operative sino-
degree of mucosal thickening demonstrated on nasal cavity. These are most common after
imaging does not necessarily correlate with frontal sinusotomy.
a b
Fig. 3.31 Mucosal inflammation. Preoperative coronal mucosal thickening, particularly in the right maxillary
CT image (a) shows mild mucosal thickening. sinus after bilateral uncinectomy, as well as correction of
Postoperative CT image (b) shows diffusely increased septal deviation
Mucoceles can form in previously operated Recurrent polyposis after surgery may require
sinuses due to blockage by the bone and/or scar revision surgery. The frequency varies with
tissue. Mucoceles are characterized by expansion comorbidities like ASA sensitivity and asthma.
of the sinus (Fig. 3.32). Although the absence of This complication is particularly predisposed by
air within the affected sinus is sine qua non for a history of cystic fibrosis, aspirin-exaggerated
mucoceles in nonoperated patients, this is not respiratory disease (AERD), and allergic fungal
necessarily the case for postoperative mucoceles. sinusitis. These patients are also prone to devel-
Postoperative scar tissue may isolate a portion of oping inspissated secretions. Polyposis is recog-
the sinus, forming a compartment where the nized by the presence of soft tissue attenuation
mucocele can form. This is sometimes termed material with smooth, convex margins on CT
“surgical ciliated cyst.” (Fig. 3.33).
Fig. 3.32 Mucocele. Coronal CT image shows a right

frontoethmoid mucocele (*) following frontal sinusotomy
Fig. 3.33 Recurrent polyposis. Sagittal (a) and coronal (b) CT images demonstrate extensive opacification of the bilat-
eral paranasal sinuses and nasal cavity with convex borders
A laterally displaced remnant of the middle turbi- Osteoneogenesis is a form of osteitis or hyperos-
nate can obstruct the frontal recess after tosis that can result from iatrogenic mucosal dis-
FESS. This can happen due to inadvertent loos- ruption. There may also be superimposed chronic
ening of the middle turbinate during surgery, inflammation or infection. On CT, osteoneogene-
whereby the turbinate can become adherent to sis appears as high-attenuation thickening of the
the lamina papyracea. The altered anatomy and sinus walls and septa (Fig. 3.35). The thickened
obstructed secretions are best depicted on coro- bone may be patchy and irregular. There may also
nal CT image (Fig. 3.34). be accompanying mucosal thickening and scar-
ring. The significance of osteoneogenesis is that it
can predispose to restenosis of the involved sinus.
Fig. 3.34 Lateralized middle turbinate. Coronal CT

image shows marked lateral deviation of the left middle
turbinate (arrow) with resultant obstruction of the frontal
and ethmoid sinuses, which are opacified (*)
Fig. 3.35 Osteoneogenesis. Coronal CT image demon-
strates areas of new bone formation in the left frontoeth-
moid recess region
3.11.11 Discussion
Performing inferior turbinectomy as part of FESS

is a somewhat controversial treatment of nasal
obstruction or snoring. Most patients experience
improved nasal breathing and some have resolu-
tion of anosmia. However, when extensive turbi-
nectomy is combined with resection of other
nasal and paranasal structures, empty nose
syndrome is a potential complication (Fig. 3.36).
This is an uncommon iatrogenic condition that
results from inadequate nasal tissue and presents
with persistent symptoms due to increased lami-
nar airflow. Nevertheless, patients experience
symptoms due to loss of normal turbulent flow Fig. 3.36 Empty nose syndrome. The patient presents
through the nasal cavity and the lack of the ability with persistent sensation of nasal obstruction following
to humidify air. extensive FESS. Coronal CT image shows the results of
septoplasty and extensive resection of the bilateral middle
and inferior turbinates, with only a residual portion of the
left inferior turbinate. There is right maxillary sinus
mucosal thickening
3.12 O
steoplastic Flap with Frontal ing the contents of the appearance of the surgical
Sinus Obliteration bed on MRI varies based on the contents as
follows:
3.12.1 Discussion
Central
The osteoplastic flap is an option for treating High T2-weighted signal intensity, no enhance-
chronic frontal sinusitis refractory to endoscopic ment: Secretions or fat
surgery, mucopyocele, extensive fractures that High T2-weighted signal intensity, enhancement:
obstruct the drainage pathways, and following Granulation tissue or inflammation
resection of large tumors in the frontal recess Low T2-weighted signal intensity, no enhance-
region. The procedure consists of performing an ment: Fibrosis or secretions
osteotomy in the coronal plane to open the fron- Low T2-weighted signal intensity, enhancement:
tal sinus (Fig. 3.37). Typically, the sinus mucosa Granulation or scar tissue
is removed and the frontal recess is packed with
fat graft or other material, and the bone flap is
then returned to its original position. Peripheral
Complications of the osteoplastic flap frontal High T2-weighted signal intensity, no enhance-
sinus obliteration include retained secretions ment: Mucosa or fluid
(Fig. 3.38); mucoceles (Fig. 3.39), which can High T2-weighted signal intensity, enhancement:
result in mass effect upon the brain or orbital Mucosa or granulation tissue
contents; extrusion of packing material Low T2-weighted signal intensity, no enhance-
(Fig. 3.40); and hardware complications ment: Fibrosis
(Fig. 3.41). While CT is useful for delineating the Low T2-weighted signal intensity, enhancement:
condition of the osteoplastic flap and associated Granulation tissue and neovascularity
hardware, MRI is useful for further characteriz-
Fig. 3.37 Osteoplastic flap expected appearance. Axial

CT image shows bilateral frontal bone osteotomies and
obliteration of the frontal sinuses
a b
Fig. 3.38 Osteoplastic flap with retained secretions. images show extensive non-enhancing material within the
Axial fat-suppressed T2-weighted (a), T1-weighted (b), frontal sinuses beneath the osteoplastic flap, as well as
and fat-suppressed post-contrast T1-weighted (c) MRI enhancing mucosa (arrow)
Fig. 3.39 Mucocele associated with frontal sinus oblit-

eration. Axial CT image shows a mucocele with intraor-
bital extension (*) that resulted from obstruction of a
supraorbital ethmoid cell by the osteoplastic flap fat pack-
ing material (arrow)
a b
Fig. 3.40 Extruded packing material and inflammatory T1-weighted MRI (b) shows that the soft tissue (arrow) in
debris. The patient presented with forehead swelling after the subgaleal space indeed communicates with the resid-
osteoplastic flap surgery. Axial CT image (a) shows a ual frontal sinus through the osteotomy. The soft tissue
fragment of fat packing in the frontal subgaleal space represents a mucocele with chronic inflammatory debris
(arrow) surrounded by soft tissue material. Sagittal
Fig. 3.41 Cosmetic deformity from deformed hardware.

Sagittal CT image demonstrates a kink in the osteoplastic
flap titanium mesh, which projects into the subcutaneous
tissues (arrow). The patient subsequently underwent hard-
ware removal
3.13 Frontal Sinus Cranialization mucoceles, trauma, arteriovenous malformations,

or infection, and serves to incorporate the frontal
3.13.1 Discussion sinus into the intracranial compartment. The pro-
cedure involves mucosal exenteration, irrigation,
Cranialization of the frontal sinuses is performed cranialization, and packing of the residual frontal
when there is disruption of the posterior wall of sinus cavity and frontonasal drainage pathway
the frontal sinus, which can be secondary to using various materials (Fig. 3.42).
a b
Fig. 3.42 Frontal sinus cranialization. The patient incurred interval frontobasal craniotomy for removal of the inner
facial fractures, which involved the frontal sinuses, which table of the frontal sinus and insertion of bone paste
is shown to be opacified on the preoperative sagittal CT (arrow) to eliminate the connection with the rest of the
image (a). Postoperative sagittal CT image (b) shows sinonasal cavities
3.14 Paranasal Sinus Stents 3.15 Frontal Sinus Trephination
Paranasal sinus stents can be used to improve Frontal sinus trephination consists of creating
intranasal drainage and to maintain patency and a defect in the sinus and is performed to pro-
drainage after sinus surgery, particularly when vide access for drainage or culture of infected
the neo-ostium measures less than 5 mm. Most material, particularly if there is intracranial
stents are self-retaining and can be inserted endo- involvement. The procedure can also be per-
scopically. The stents are usually a temporary formed in conjunction with functional endo-
measure, but occasionally remain for over 1 year. scopic sinus surgery for enhanced visualization
Potential complications include dislodgment and and irrigation of the frontal sinus and for resec-
obstruction, especially for long-term stents. In tion of type IV frontal cells, which cannot be
particular, stents can predispose to scarring. attained from an endonasal approach. The
Sinus stents are hollow tubular structures with a trephination defect is usually located approxi-
relatively wide flange or “mushroom” at one end mately 1 cm lateral to the midline, and an
in order to secure the device in position. CT is external drainage catheter can be left in posi-
useful for evaluating the position of the stent and tion (Fig. 3.44).
associated complications, if needed (Fig. 3.43).
Fig. 3.43 Sinus stent. The patient was treated for frontal
sinus obstruction secondary to a mass lesion. Sagittal CT
image demonstrates a right frontal sinus stent that is actu-
ally positioned too far inferiorly
Fig. 3.44 Frontal sinus trephination with catheter.

Sagittal CT image shows a catheter that exits through the
skin from the opacified right frontal sinus via a window in
the outer table of the inferior sinus projecting through the
skin
3.16 Decompression, Enucleation, treat keratocystic odontogenic tumors, which orig-

and Ostectomy inate in the maxillary alveolus and extend into the
maxillary sinus. In order to minimize the recur-
3.16.1 Discussion rence rate, adjunctive measures such as ostectomy
or en bloc resection can be performed. Furthermore,
Ostectomy and drainage can be used to treat cystic cryotherapy and instillation of the cyst cavity with
lesions that involve maxillary sinuses. This Carnoy’s solution or balsam of Peru after enucle-
involves creating a Caldwell-Luc-type defect in ation can be used to ablate residual tissue
the maxillary antrum and inserting a drainage tube (Fig. 3.46). Recurrent odontogenic cysts manifest
in order to decompress the lesion (Fig. 3.45). as gradual scalloping of the maxillary bone at the
Alternatively, surgical enucleation can be used to resection site on follow-up imaging (Fig. 3.47).
a b
Fig. 3.45 Decompression and drainage. The patient is passes across a wide antrostomy. Coronal CT (b) image
status post unroofing of a left maxillary odontogenic kera- obtained 1 year later demonstrates interval removal of the
tocyst via decompression and irrigation. Coronal CT drain and resolution of the lesion
image (a) demonstrates a right maxillary sinus drain that
a b
Fig. 3.46 Enucleation and ostectomy. Preoperative coro- ity. Postoperative coronal CT image (b) obtained 1 year
nal CT image (a) shows an odontogenic keratocyst (*) following enucleation and packing with balsam of Peru
projecting into the left maxillary sinus. The cyst is air shows soft tissue filling the space previously occupied by
filled due to prior spontaneous drainage into the oral cav- the cyst (arrow)
a b
Fig. 3.47 Residual/recurrent lesion. The patient is status (a) shows the left maxillary sinus ostectomy site (arrow).
post enucleation and ostectomy for a left maxillary odon- Follow-up CT at 1 year (b) demonstrates interval scallop-
togenic keratocyst. Initial postoperative coronal CT image ing of the maxillary bone (arrow)
3.17 Maxillectomy the p terygopalatine fossa becomes altered by scar

and Palatectomy tissue (Fig. 3.53), which should not be confused
with tumor recurrence on imaging, since these can
3.17.1 Discussion feature enhancing soft tissue on imaging. Recurrent
tumors can have variable appearances, but most
Maxillectomy consists of removing at least a por- commonly appear as growing mass lesions located
tion of the maxillary sinus. The degree of resection at the surgical margins (Fig. 3.54). Comparison
ranges from partial/lateral maxillectomy, total max- with prior studies, short-term follow-up, PET-CT,
illectomy, maxillectomy with palatectomy, and or biopsy should be considered in ambiguous cases.
pterygoid plate resection to craniofacial resection, Of note, synthetic materials, such as polytetrafluo-
depending on the extent of disease (Figs. 3.48 and roethylene, that are sometimes used as slings in
3.49). Obturators are often used to occlude the oro- reconstruction of the soft tissues overlying the max-
nasal communication that results from palatectomy illectomy can produce foreign body granulomas,
(Fig. 3.50). Many of these devices contain metal which can mimic tumor recurrence (Fig. 3.55).
parts and should be removed prior to imaging in Similarly, dacryocystoceles in patients treated for
order to minimize artifact. Obturators otherwise sinonasal cancer can mimic recurrent tumor.
have variable appearances on CT, ranging from However, these lesions characteristically appear as
hyperattenuating to heterogeneous to air-filled com- fluid-filled structures in the anteromedial orbit
ponents. Bone and soft tissue flaps can also be used (Fig. 3.56). Dacryocystoceles may form secondary
to reconstruct the surgical resection defects to obstruction by recurrent tumor, ablative surgery,
(Figs. 3.51 and 3.52). In addition, titanium mesh, radiation therapy, or certain chemotherapeutic
plates and screws, and plastic slings are often used agents. Finally, infected maxillectomy sites may be
to support the constructs. Both CT and MRI with treated with implantation of antibiotic impregnated
contrast are useful for follow-up, particularly to methyl methacrylate beads, which appear as hyper-
asses for recurrent tumor. With extensive resections, attenuating on CT (Fig. 3.57).
a b
Fig. 3.48 Partial maxillectomy and total palatectomy. bilateral medial maxillary sinus walls and the hard palate,
The patient has a history of leukemia status post bone resulting in continuity between the oral cavity, maxillary
marrow transplant with graft-versus-host disease invasive sinuses, and nasal cavity. There are mandibular dental
fungal infection involving the hard palate and maxillary amalgam artifacts that should not be confused for a pros-
sinuses. Bilateral partial maxillectomy was performed. thesis related to the surgery
Coronal (a) and 3D CT (b) images show resection of the
a b
Fig. 3.49 Total maxillectomy. Axial (a) and 3D (b) CT images show the absence of the vast majority of the left maxil-
lary bone, leaving the pterygoid plate intact, but sclerotic
Fig. 3.50 Total maxillectomy and palatectomy with

obturator. Axial (a) and coronal (b) CT images show
complete resection of the left maxillary sinus,
including the orbital floor, and left hemipalatectomy.
An obturator device is present (arrows)
Fig. 3.51 Palatectomy with radial forearm free flap

a
reconstruction. Coronal (a) and sagittal (b) CT images
show resection of the hard and soft palate. The defect
is closed using a soft tissue graft (arrows)
b
a b
Fig. 3.52 Palatectomy and maxillectomy with osteomyo- (arrows) has been used to reconstruct the contours of the
cutaneous flap reconstruction. The patient has a history of maxillary alveolus, and the myocutaneous portion of the
desmoplastic ameloblastoma extending into the right graft forms the floor of the maxillary sinus and nasal cav-
maxillary sinus. Coronal (a) and 3D (b) CT images show ity, creating a neoantrum (*)
right partial maxillectomy and palatectomy. Fibular graft
a b
Fig. 3.53 Postoperative pterygopalatine fossa. The tomy (arrows). Axial T2-weighted (b) and post-contrast
patient underwent maxillectomy for breast cancer metas- T1-weighted (c) MR images show that this tissue has low
tasis. Axial CT image (a) shows amorphous fibrovascular T1 and T2 signal, but enhances (arrows)
tissue at the posterior margin of the left partial maxillec-
Fig. 3.56 Postoperative dacryocystocele. Coronal CT

image shows postoperative findings related to left sinona-
Fig. 3.54 Flap reconstruction with tumor recurrence. sal surgery, with dilatation of the lacrimal sac (arrow)
The patient has a history of squamous cell carcinoma and
is status post right total maxillectomy with flap recon-
struction. Axial CT image shows a necrotic mass (arrow)
at the reconstruction flap margin
Fig. 3.55 Foreign body reaction. Axial CT image shows

soft tissue surrounding a polytetrafluoroethylene sling
(encircled)
Fig. 3.57 Antibiotic-impregnated beads. 3D CT image

shows numerous hyperattenuating beads in the bilateral
maxillectomy cavities in a patient who underwent prior
odontogenic myxoma debulking with superimposed
infection of the surgical bed
3.18 Maxillary Swing osteotomies through and around the maxillary

sinus in order to free the structure and rotate it
3.18.1 Discussion laterally and expose the underlying lesions
(Fig. 3.58). The infraorbital nerve is often sacri-
The maxillary swing approach is sometimes used ficed during the procedure. Recurrent tumors can
to resect nasopharyngeal and pterygopalatine spread through the osteotomy sites (Figs. 3.58
fossa tumors. The technique includes several and 3.59).
a b
c d
Fig. 3.58 Maxillary swing. The patient has a history of nasal process of the maxillary bone, the posterior maxil-
nasopharyngeal carcinoma, which was resected via the lary wall, the zygomatic process, and the midline hard pal-
maxillary swing approach. Axial (a, b) and coronal (c, d) ate, in order to allow the maxillary sinus to rotate laterally
CT images show multiple osteotomy sites, most of which (curved yellow arrows). The left infraorbital nerve was
are secured by microfixation plates, including the left sacrificed by the osteotomy
a b
c
d
Fig. 3.59 Recurrent tumor. The patient has a history of maxillary wall osteotomy defect. The corresponding axial
nasopharyngeal carcinoma resected via a maxillary swing T2-weighted (b), T1-weighted (c), and post-contrast
approach. Axial CT image (a) demonstrates a nodular T1-weighted (d) MR images show that the intermediate
lesion (arrows) that insinuates across the left posterior T2 signal lesion enhances (arrows)
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Imaging the Postoperative Scalp
and Cranium 4
Daniel Thomas Ginat, Ann-Christine Duhaime,
4.1 Occipital Nerve Stimulator generator that is typically located subcutaneously

in the chest. The main complications of this tech-
4.1.1 Discussion nique include electrode dislodgment and infec-
tion. Radiographs can depict the course of the
Occipital neuralgia that does not respond to con- leads, which is a nearly horizontal orientation in
servative management is sometimes responsive the occipital subcutaneous tissues, perpendicular
to occipital nerve stimulation. Unilateral or bilat- to the course of the greater occipital nerves
eral electrodes are implanted in the posterior (Fig. 4.1). CT or MRI can be used to evaluate the
scalp subcutaneous tissues in contact with the extent of clinically suspected infection and other
occipital nerves. The device is connected to a soft tissue complications.

Department of Radiology,
A.-C. Duhaime, M.D.
Harvard Medical School,
Massachusetts General Hospital, Boston, MA, USA
M.D. Moisi, M.D., M.S.
Swedish Neuroscience Institute, Seattle, WA, USA

DOI 10.1007/978-3-319-52341-5_4
Fig. 4.1 Occipital nerve stimulator. The patient has a history of intractable migraine headaches. Frontal (a) and lateral
(b) radiographs of the skull show the electrodes situated in the bilateral occipital subcutaneous tissues (arrows)
4 Imaging the Postoperative Scalp and Cranium 119
4.2 Tissue Expander expander appears as a fluid-filled sac within

the scalp (Fig. 4.2). A radial fold may project
4.2.1 Discussion into the lumen of the expander. These can
attain relatively large sizes. Identification of an
Tissue expanders are used to stretch the skin infusion port helps distinguish the device from
for later use in various reconstructive proce- an abscess. Many of the infusion ports have
dures, such as to correct burn alopecia. These magnetic components that are not MRI com-
devices are essentially fluid-filled silicone patible. Complications related to tissue expand-
sacs, connected to an infusion port. The con- ers include extrusion and rupture. The presence
ventional expander requires serial filling over a of a radial fold is a normal feature of certain
period of several months. Osmotic self-filling tissue expanders and should not be mistaken
expanders are also available. On CT, the for rupture.
a b
Fig. 4.2 Scalp tissue expander. The patient has a history rior to the craniectomy defect. Photograph of an unfilled
of severe burns to the face. Sagittal CT image (a) shows a expander (b) (Courtesy of Melissa Guilbeau)
saline-filled skin expander device within the scalp, poste-
4.3 Temporal Fossa Implants other surgeries. The contours of the temporal
fossa can be augmented using implants, such as
4.3.1 Discussion prefabricated porous high-density polyethylene
(Fig. 4.3), silicone (Fig. 4.4), and methyl meth-
Soft tissue deficiency in the temporal fossa can acrylate (Fig. 4.5). The implants are usually
produce cosmetic impairment and can result inserted via a hemicoronal approach and can be
from the transposition of temporalis myofascial secured using titanium screws to the underlying
flaps and tumor debulking procedures, among bone.
a b
Fig. 4.3 Porous polyethylene temporal fossa implant. teration. Axial T2-weighted (b) and axial T1-weighted (c)
Axial CT image (a) shows a low-attenuation polyethylene MR images in a different patient show a polyethylene
implant with inner ridged surface positioned in the left implant in the right temporal fossa (arrows) with near-
temporal fossa (arrows). There is also left orbital exen- anatomic contours of the overlying scalp
Fig. 4.5 Methyl methacrylate temporal fossa implant.

Axial CT image shows a heterogeneous plate implanted in
the right temporal scalp soft tissues (arrow)
Fig. 4.4 Silicone temporal fossa implant. The patient has

a history of neurofibromatosis and is status post tumor
debulking. Axial T2-weighted MRI shows a low-intensity
plate in the right temporal scalp subcutaneous tissues
(arrow)
4.4 ohs Micrographic Surgery

M sequential thin sections, which are concurrently
and Skin Grafting examined under the microscope. The process is
repeated until no remaining tumor is identified
4.4.1 Discussion microscopically. When discernible on imaging,
the defects characteristically appear as well-
Mohs micrographic surgery is a technique that defined cavities in the skin and underlying soft
enables skin neoplasms to be fully resected while tissues (Fig. 4.6). Large defects can be recon-
maximizing preservation of normal tissues. Mohs structed using split-thickness skin grafts (Fig. 4.7),
surgery consists of removing the tumor via flaps, or synthetic materials such as AlloDerm.
Fig. 4.6 Mohs micrographic surgery. The patient has a

history of basal-cell carcinoma of the scalp. Coronal CT
image shows a well-defined defect in the left scalp
(encircled)
a b
Fig. 4.7 Split-thickness skin graft. Axial T2-weighted (a) and T1-weighted (b) MR images show that the skin graft
(arrows) is thinner than the adjacent normal scalp
4.5 otational Galeal Flap Scalp

R 4.6 ree Flap Reconstruction
F
Reconstruction of Complex Scalp Defects
Galeal flaps, such as the retroauricular rotation Free flap transfer is used for repairing complex
flap, can be used to cover scalp defects as large as scalp defects in order to provide functional, cos-
60% of the scalp surface area. Galeal flaps are metic, and structural support when the use of
comprised of fascia, subcutaneous tissue, and skin grafts, locoregional flaps, and tissue expand-
vascular components. In the early postoperative ers is not feasible. The latissimus dorsi myocuta-
period, a remote donor site defect can be appar- neous flap is particularly useful for subtotal and
ent, such as with “flip-flop” flaps (Fig. 4.8). total skull reconstruction, in which there is con-
Galeal flaps can incur essentially the same com- siderable dead space (Fig. 4.9). Latissimus dorsi
plications as other types of flaps, including infec- flaps can be harvested with ribs (myo-osseocuta-
tion, tumor recurrence, and necrosis, as well as neous) or combined with titanium mesh for
dehiscence and alopecia. added support. Omental flaps are another option
for closing large scalp and cranium defects
(Fig. 4.10). These contain mostly adipose tissues
and are covered by skin grafts. Other donor tis-
sues for free flap transfer include rectus abdomi-
nis muscle flaps, scapular flap, radial forearm
flap, and anterolateral thigh flap. Vascular supply
is typically obtained via anastomosis to the
superficial temporal artery and vein or at times
the occipital artery. Complications include
delayed flap failure, which requires secondary
reconstruction, neck hematoma, venous throm-
bosis, skull base infection, large wound dehis-
cence, small wound dehiscence, donor site
hematoma and seroma, and cerebrospinal fluid
leak.
Fig. 4.8 Galeal flap, early postoperative period. The

patient has a history of infected hardware, necrotic bone,
and open scalp wound. A rotational scalp flap was
advanced to cover the defect after wound debridement.
Axial CT image shows a left parietal skull defect covered
by a rotational fasciocutaneous flap. There is surgical
packing material (arrow) in the contralateral donor site
a b
Fig. 4.9 Latissimus dorsi muscle flap. The patient has a regions and an overlying muscle flap. Characteristic mus-
history of extensive squamous cell carcinoma of the scalp, cle fibers are apparent in the flap on the axial T1-weighted
with invasion of the calvarium. Axial CT image (a) shows MRI (b). Axial post-contrast Tl-weighted MRI (c) shows
titanium cranioplasty of the right occipital and parietal enhancement of at least some of the muscle fibers
4.7 Scalp Tumor Recurrence
4.7.1 Discussion
Most recurrent tumors manifest within the first

2 years following resection and are most c ommon
in the tumor bed near the anastomosis. Imaging
can detect both locoregional recurrence and the
extent of intracranial extension of recurrent
tumors (Fig. 4.11). Postoperative imaging can
also help in distinguishing tumor recurrence from
fibrosis related to the surgery or radiation therapy.
Recurrent tumors typically appear as nodular foci
of enhancement and have higher T2-weighted sig-
nal intensity on MRI than fibrosis.
Fig. 4.10 Omental free flap. The patient is status post
motorcycle accident during which loss of cranial bone
occurred. Coronal CT image shows the flap overlying the
right hemicraniectomy site contains fat and omental ves-
sels and is covered by skin graft
a b
Fig. 4.11 Skin tumor recurrence. The patient has a history underlying skull. CT images obtained 14 months after sur-
of locally invasive squamous cell carcinoma, presenting as gery (b) show an enhancing mass (arrow) deep to the myo-
a large fungating scalp lesion. Axial preoperative CT cutaneous free flap. There are also several metastatic
image (a) shows a right frontal scalp mass that invades the nodules in the left scalp
4.8 Burr Holes insertion. Burr holes are surgical defects that
traverse the full thickness of the calvarium cre-
4.8.1 Discussion ated using various drills and can be packed with a
variety of materials, such as bone wax and methyl
Burr hole craniostomy is a commonly performed methacrylate and may be covered with a plate
maneuver as part of creating craniotomy flaps, (Fig. 4.12). Linear enhancement along the edges
stereotactic biopsy, hematoma decompression, of burr holes is commonly observed as vascu-
ventricular endoscopic procedures, insertion lar granulation tissue forms, thereby potentially
of ventricular catheters, drains, and electrode mimicking abscesses or neoplasms (Fig. 4.13).
a b
Fig. 4.12 Burr holes. Axial CT image (a) shows a right acrylate filling the bifrontal burr holes (arrows). Axial CT
parietal calvarium defect that matches the contours of the image (c) shows a metallic burr hole cover (arrow)
drill (encircled). Axial CT image (b) shows methyl meth-
a b
Fig. 4.13 Burr hole neovascularization. Axial T1-weighted (a) and post-contrast fat-suppressed T1-weighted (b) MR
images show a left frontal burr hole with marginal enhancement (arrows)
4.9 Craniotomy Hinge craniotomy is an alternative to tradi-

tional decompressive craniectomy and allows
4.9.1 Discussion swollen brain parenchyma to expand extracrani-
ally while avoiding some of the complications
Craniotomy consists of opening the cranial vault associated with cranial revision. The bone flap is
by removing a bone flap during the course of left attached on one side to the scalp soft tissues,
surgery and replacing it at the completion of the usually the temporalis muscle. This results in the
procedure, as opposed to craniectomy in which the appearance of an outwardly displaced bone flap
bone is removed and not replaced. Once the skull on CT (Fig. 4.17).
is exposed by raising the overlying scalp and peri- The normal imaging appearance of the cra-
cranial flap, burr holes are drilled, from which the niotomy site can evolve over time. In the early
bone flap is created using a saw or drill. The bone postoperative period, the bone flap margins are
flap is set aside during the procedure and replaced sharp and should align precisely with the rest
upon completion of the surgery. Some of the stan- of the skull, unless a craniectomy was done to
dard types of craniotomy include the following: provide more surgical accessibility. The extent
of dural enhancement that normally occurs after
• Pterional craniotomy ranges considerably. Dural enhance-
• Orbitozygomatic ment is present in the majority of patients fol-
• Modified orbitozygomatic lowing cranial surgery and can be seen within
• Frontal or bifrontal the first postoperative day (Fig. 4.18). The pres-
• Parietal or biparietal ence and degree of enhancement are largely
• Subtemporal dependent on the time elapsed since the time of
• Anterior parasagittal surgery and the types of substitutes used during
• Posterior parasagittal closure, which in some cases can persist indefi-
• Suboccipital nitely. Dural enhancement tends to be apparent
• Retrosigmoid earlier and lasts longer with gadolinium-based
• Pre-sigmoid contrast than with iodine-based contrast.
• Far lateral Granulation tissue also normally forms along the
• Hemicraniotomy edges of the bone flap, which manifests as linear
enhancement that is often visible on MRI and
Skin staples are often used to close the scalp often accompanies dural enhancement. This type
flap after surgery and can be present on imaging of enhancement usually persists up to 1 year fol-
during the early postoperative period (Fig. 4.14). lowing craniotomy.
A variety of devices and methods are available to Pneumocephalus is the presence of intracra-
secure cranial bone flaps following craniotomy. nial air and is an expected finding after recent
The most commonly used are microfixation cranial surgery. Indeed, virtually all patients
plates or clamps (Fig. 4.15). Microfixation plates exhibit some degree of pneumocephalus during
are often composed of titanium, which produces the immediate postoperative period.
minimal streak or susceptibility artifact. Pneumocephalus can be identified by air attenua-
Complications related to the presence of micro- tion on CT and signal voids on MRI (Fig. 4.19).
fixation plates and screws, such as transcranial Regardless of the location, pneumocephalus nor-
migration, are uncommon, except in young chil- mally resolves within 3 weeks of surgery.
dren, where absorbable hardware or suture may During the early postoperative period, typical
be used. Stainless steel wires threaded across the changes also occur in the soft tissues overlying
craniotomy margin to the bone plates is no longer the craniotomy site, including temporalis muscle
performed in developed countries, but may still swelling (Fig. 4.20), which likely represents
be encountered on imaging (Fig. 4.16). edema due to manipulation during surgery.
Fig. 4.14 Skin staples. Coronal CT image shows numer-

ous staples (arrows) used to close the skin flap after
craniotomy
a b
c d
Fig. 4.15 Microfixation plates. 3D CT image (a) shows a flap. Photographs of a variety of low-profile fixation plates
variety of titanium microfixation plates securing the bone (b–d) (Courtesy of Patricia Smith and Sarah Paengatelli)
Fig. 4.17 Hinge craniotomy. Coronal CT image shows

that the right parasagittal bone flap is not secured to the
adjacent calvarium in order to allow the edematous brain
to expand freely across the craniotomy defect
Fig. 4.16 Fixation wire. Axial CT image shows a stain-
less steel wire that secures the bone flap (arrow)
Fig. 4.18 Expected dural enhancement after craniotomy.

Coronal post-contrast T1-weighted MRI shows linear
dural enhancement deep to the craniotomy flap (arrow).
There is also enhancement along the edges of the bone flap
(arrowheads)
Fig. 4.20 Temporalis muscle swelling. Axial CT image

obtained after recent left pterional craniotomy shows dif-
fuse enlargement of the left temporalis muscle (arrow)
Fig. 4.19 Postoperative pneumocephalus. Axial CT

image (a) shows and small amount of left frontal con-
vexity extra-axial pneumocephalus. Axial SWI image in
another patient (b) shows scattered foci of supratentorial
signal voids from subarachnoid pneumocephalus after
posterior fossa surgery
4.10 Cranioplasty appears as homogeneously hyperattenuating on

CT, similar in attenuation as natural bone
4.10.1 Discussion (Fig. 4.23). On MRI, the hydroxyapatite appears
as a signal void.
Intraoperatively fashioned acrylic cranioplasty is Titanium mesh is commonly used as a cranio-
composed of methyl methacrylate resin that can plasty material. These plates generally produce
be molded to a desired shape on the surgical field. good cosmetic results and minimal discomfort.
The material tends to appear heterogeneous on Titanium produces minimal streak artifact on CT
CT and low signal on MRI (Fig. 4.21). The mate- (Fig. 4.24). Solid titanium plates are now infre-
rial often contains multiple foci of air due to the quently used but may be observed on follow-up
exothermic reaction that occurs when formed. imaging (Fig. 4.25).
The trapped bubbles should not be confused with Porous polyethylene implants are also suitable
infection. The methyl methacrylate at times can for covering cranial defects. This type of implant
migrate prior to hardening, the appearance of is also custom created for each patient using a
which can potentially mimic hemorrhage on CT. computer-aided design system and 3D CT data.
Preformed acrylic methyl methacrylate plates The material enables soft tissue and bone
are specially molded to fit individual craniec- ingrowth and displays low attenuation on CT and
tomy defects using a computer-aided design sys- low signal intensity on T2- and T1-weighted
tem and 3D CT data. These flaps are usually MRI sequences (Fig. 4.26).
secured to the adjacent calvarium using titanium Synthetic bone grafts that are biocompat-
plates and are thus continuous with the calvar- ible have been developed for cranioplasty. For
ium. On CT, preformed acrylic plates demon- example, Bioplant HTR Synthetic Bone is a
strate homogeneous intermediate attenuation, microporous composite of poly(methyl methac-
around 100 HU (Fig. 4.22). Unlike the acrylic rylate) (PMMA), polyhydroxyethylmethacrylate
plates prepared intraoperatively, the preformed (PHEMA), and calcium hydroxide. On CT, the
plates do not contain air bubbles. However, the HTR cranioplasty appears as heterogeneous with
preformed acrylic plates contain holes that are an overall attenuation that is greater than soft tis-
drilled to promote tissue ingrowth and leave a sue but lower than bone (Fig. 4.27).
pathway to prevent accumulation of fluid in the Autologous bone grafts can also be used for
epidural space. cranioplasty. These are often used in the form of
Hydroxyapatite cement paste is sometimes split calvarial grafts in which the inner table is
used to close off small gaps in the calvarium. It separated from the outer table in order to increase
can be molded to match the particular anatomy surface area for maximal coverage of a craniec-
and can be applied in conjunction with other tomy defect (Fig. 4.28).
materials, such as titanium mesh. The cement
a b
Fig. 4.21 Intraoperatively fashioned acrylic cranio- nioplasty plate (arrow) has low signal on the correspond-
plasty. Axial CT image (a) shows an acrylic cranioplasty ing T1-weighted MRI (b)
flap containing low-attenuation bubbles (arrow). The cra-
a b
Fig. 4.22 Preformed acrylic cranioplasty. Axial CT contours of the calvarium. The plate is traversed by
image (a) demonstrates a high-attenuation left frontal numerous holes to allow tissue ingrowth. Photograph of
acrylic cranioplasty (arrow), conforming to the natural customized acrylic cranioplasty flap without holes (b)
Fig. 4.23 Hydroxyapatite cement. Coronal CT image

shows the hyperattenuating material (arrow) filling a gap
between the craniotomy flap and the adjacent skull
a b
Fig. 4.24 Titanium mesh cranioplasty. Axial (a) and 3D surface rendered (b) CT images show a titanium mesh that
spans a left frontal craniectomy defect. Photograph (c) of a titanium mesh (Courtesy of Caroline Dufault, RN)
Fig. 4.25 Titanium plate. Axial CT image shows the

metal attenuation plate (arrow) that spans the left retrosi-
gmoid craniectomy, which was performed in the 1980s
a b
Fig. 4.26 Porex (porous polyethylene) cranioplasty. Axial CT image (a) shows bilateral low-attenuation implants
(arrow). The cranioplasty material also displays low signal on T2-weighted (b) and T1-weighted (c) MR images
Fig. 4.27 Synthetic (HTR) bone graft cranioplasty.

Coronal CT image shows right hemicraniectomy with het-
erogeneously hyperattenuating cranioplasty material
(arrow)
a b
Fig. 4.28 Split-thickness bone graft cranioplasty. Initial arrow). Corresponding coronal CT image (c) shows the
3D CT image (a) shows a right temporal skull defect (*). split calvarium at the donor site (arrow) and the reposi-
3D CT image after cranioplasty (b) shows interval har- tioned split calvarial graft in the right temporal region
vesting of bone from the right parietal calvarium and (encircled)
repositioning it into the temporal skull defect (curved
4.11 Autocranioplasty good cosmetic results. An alternative is subcu-

taneous storage, which allows the bone flap to
4.11.1 Discussion stay with the patient and may decrease the risk of
devitalization and/or infection of the flap. Bone
Several options are available for storing autolo- flaps can be kept fresh by implanting them into
gous bone flaps after decompressive craniec- subcutaneous pockets in the abdomen and may
tomy for delayed autocranioplasty. Often, bone be encountered on imaging (Fig. 4.29). Bone
flaps are stored in a sterile freezer. This approach grafts stored in this manner tend to undergo
preserves the bone flap very well, providing remodeling.
Fig. 4.29 Autocranioplasty. Frontal radiograph (a) and

axial CT image (b) show a skull flap (arrows) embedded
within the right lower quadrant subcutaneous tissues
4.12 Craniectomy, other hand, bilateral (bifrontal) craniectomy is

the Meningogaleal Complex, performed when both sides of the brain are
and Suboccipital Craniectomy affected and consists of removing the calvarium
of the anterior cranial fossa to the coronal sutures.
4.12.1 Discussion Decompressive craniectomy has characteristic
imaging findings. Following craniectomy, the
Decompressive craniectomy is performed in order galea aponeurotica becomes juxtaposed against
to decrease intracranial pressure when medical the dura. Scar tissue then forms between these
management alone is insufficient and is most two layers, which creates the meningogaleal
commonly used in the setting of traumatic brain complex beneath the subcutaneous tissues.
injury, subarachnoid hemorrhage, intraparenchy- Normally, this complex measures between 2 and
mal hemorrhage, and cerebral infarction. The pro- 6 mm in thickness. On CT, the meningogaleal
cedure consists of removal of portions of the complex is slightly hyperattenuating, while the
skull, which is not replaced during the procedure. appearance on MRI is variable depending on the
Hemicraniectomy is performed when one side of degree of hypervascular tissue that is incorpo-
the brain is affected and usually entails removal of rated (Fig. 4.30). Smooth, uniform enhancement
bone in the frontoparietotemporal region. On the is expected on CT and MRI.
a b
Fig. 4.30 Craniectomy and normal meningogaleal Axial T2-weighted (c), T1-weighted (d), and post-contrast
complex.3D (a) and coronal (b) CT images show a large T1-weighted (e) MRI sequences in a different patient
right hemicraniectomy defect and a normal meningoga- show enhancement of the left hemicraniectomy meningo-
leal complex in which the dura is juxtaposed to the scalp. galeal complex (arrows)
c d
4.13 C
ranial Vault Surgical Management of raised intracranial pressure in
Remodeling syndromic multi-suture craniosynostosis by cra-
for Craniosynostosis nial vault expansion can be achieved by posterior
calvarial vault expansion using distraction osteo-
Sagittal synostosis is a relatively common type of genesis (Fig. 4.34).
craniosynostosis that results from premature Endoscopic craniosynostosis repair is a mini-
fusion of the sagittal suture. Surgery is performed mally invasive treatment option available to
for relieving associated elevated intracranial pres- patients under 6 months of age. The technique
sure and for cosmesis. There are several approaches consists of performing a strip craniectomy,
to correcting the deformity including bone removal whereby the affected suture is resected (suturec-
and reshaping with barrel stave osteotomies tomy). This results in a linear gap along the
(Fig. 4.31), endoscopic craniectomy with adjuvant course of the suture and allows the calvarium to
use of a remodeling helmet, and placement of dis- be remodeled with postoperative helmet therapy
traction devices. Follow-up imaging may be (Fig. 4.35). Endoscopic-assisted wide-vertex cra-
obtained for planning additional surgical recon- niectomy and barrel stave osteotomies can also
struction or if complications are suspected. be performed.
Correction cranioplasty and orbitofrontal Calcium phosphate cement has been used to
advancement is a treatment option for trigono- fill bony defects created during cranial remodel-
cephaly. This procedure generally entails take ing surgery for craniosynostosis repair in the
down of a bifrontal bone flap, removal of the pediatric population and is intended to be osteo-
orbital bandeau, followed by cranial vault recon- conductive. The bone cement initially has a
struction and advancement (Fig. 4.32). The use of putty-like consistency and can be applied in an
reabsorbable fixation plate and screws yields inlay or onlay fashion. The material can undergo
superior cosmetic results and can appear as tiny bioresorption and generally does not impede the
bone defects without discernible radio-attenuating actively growing calvarium. On CT, calcium
components otherwise on CT. The orbitofrontal phosphate cement appears as hyperattenuating
advancement procedure can be augmented using with respect to bone (Fig. 4.36). The appearance
onlay cements (Fig. 4.33). The incidence of com- of the junction between the native bone and the
plications is about 2%, and there is a 12% reop- bone cement is variable, ranging from a sharp
eration rate. Residual hypotelorism usually interface to a lucent gap when resorption occurs.
autocorrects, while bitemporal depressions may The bone cement tends to be brittle and can also
develop over time. High-resolution craniofacial fragment. The presence of bone cement fragmen-
CTs with 3D reformatted images are particularly tation does not necessarily imply palpable
useful for postoperative assessment and planning motility and is not particularly problematic if
additional surgical intervention, if needed. fragmentation occurs as an onlay.
a b
Fig. 4.31 Barrel stave osteotomies and cranial remodel- demonstrates multiple parietal barrel stave osteotomies,
ing for scaphocephaly. Preoperative 3D CT image (a) resulting in improved skull morphology
shows dolichocephaly. Postoperative 3D CT image (b)
a b
Fig. 4.32 Correction cranioplasty and orbitofrontal top view 3D CT (d) images show osteotomies along the
advancement. The patient has a history of nonsyndromic orbital bandeau (arrowheads). The multiple tiny holes in
trigonocephaly. Preoperative frontal (a) and top view 3D the calvarium correspond to the attachment sites of the
CT (b) images show fusion of the metopic suture, with absorbable plates, which are otherwise not visible
prominent frontal beaking. Postoperative frontal (c) and
c d
Fig. 4.33 Orbitofrontal advancement surgery with onlay

cement. Axial CT image shows the hyperattenuating arti-
ficial bone cement superficial to the reconstructed frontal Fig. 4.34 Posterior cranial vault distraction. Lateral 3D
bone. The presence of seroma displaces the cement away CT image of the skull shows parietal osteotomies with a
from the surface of the calvarium and bifrontal distraction device in position (arrow)
craniotomies
a b
Fig. 4.35 Endoscopic strip craniectomy. Preoperative 3D CT image (b) shows interval resection of the right
3D CT image (a) shows asymmetric right coronal synos- coronal suture (arrows), resulting in improved contours of
tosis, resulting in deformity of the calvarium. Postoperative the skull
Fig. 4.36 Calcium phosphate cement for craniosynosto-

sis repair. 3D CT image shows several areas of the hyper-
attenuating cement used to fill the craniectomy defects
4.14 C
ranial Vault Encephalocele
a
Repair
4.14.1 Discussion
Traditional management of encephaloceles con-

sists of resecting the abnormal herniated brain
tissue and closing the wound via primary inten-
tion if there is sufficient skin available (Fig. 4.37),
with the goal of avoiding new deficits related to
extended surgery. Cranioplasty can be performed
at the same time as the primary surgery or at a
later time, using materials such as methyl meth- b
acrylate, hydroxyapatite bone cement, deminer-
alized bone matrix, and autologous grafts, which
can be harvested from the adjacent calvarium, for
example (Fig. 4.38). If a substantial amount of
functional brain tissue has herniated through the
encephalocele sac, expansile cranioplasty can be
performed. This technique consists of recon-
structing the calvarial defect with autologous
bone graft harvested from the adjacent parietal
region. This approach effectively enlarges or
extends the intracranial cavity to encompass the
herniated brain tissue.
Fig. 4.37 Occipital encephalocele resection and primary

closure. Preoperative sagittal CT image (a) shows hernia-
tion of dysplastic brain tissue (*) through a posterior cal-
varial defect. Postoperative sagittal T1-weighted MRI (b)
shows interval resection of the herniated brain tissue and
closure of the defect via duraplasty and skin (arrow)
a b
c d
Fig. 4.38 Frontonasal encephalocele repair. Preoperative Postoperative sagittal (c) and 3D (d) CT images show
sagittal (a) and 3D (b) CT images show a frontonasal interval resection of the encephalocele and repair of the
encephalocele herniating through a midline skull defect. defect using calvarial bone graft (arrows)
4.15 Box Osteotomy bone flap to help remove excess interorbital bone
and to mobilize the orbits. Once the orbits are
Hypertelorism can be corrected by performing repositioned closer to one another, they can be
box osteotomy, which involves creating a frontal secured with plates and screws (Fig. 4.39).
Fig. 4.39 Box osteomtomy. Preoperative 3D CT image (a) shows craniofacial dysplasia with hypertelorism.
Postoperative 3D CT image (b) shows interval medial repositioning of the orbits and reconstruction of the nose with
bone graft
4.16 Absorbable Hemostatic ulation cascade. The material has a rather char-
Agents acteristic appearance of a pseudomass with
relatively low signal speckles in a background
4.16.1 Discussion of hyperintensity on T2-weighted MRI
(Fig. 4.42), when clusters have formed with
Several types of topical absorbable hemostatic fluid absorbed by the granules and retained in
agents are available for neurosurgical procedures, the matrix. These microbubbles and clot forma-
including cellulose-, gelatin-, and collagen-based tion in the matrix cause magnetic field inhomo-
agents and thrombin and fibrin glue. geneity with T2* effects evident by blooming
Oxidized regenerated cellulose, such as susceptibility of the gelatin-thrombin matrix in
Surgicel, is available in the form of a fabric that the surgical cavity.
can be used to line the margins of resection cavi- Neurosurgical procedures can involve a
ties or packed tightly to control a more focal great degree of complexity and occur over
source of bleeding. Implanted oxidized cellulose extended periods of time, and the contents of
has been reported to mimic abscesses and masses the surgical cavity can be obscured by blood
on postoperative imaging. On CT, oxidized cellu- products. These circumstances can make it dif-
lose often displays low attenuation, and on MRI, it ficult for the neurosurgeon to visually identify
usually shows low signal on T2, but variable T1 surgical paraphernalia left within the surgical
signal (Fig. 4.40). Sometimes, the presence of field. However, radiopaque markers can help to
high T1 signal can potentially mimic residual localize a retained sponge or instrument with
tumor on contrast-enhanced images. The hemo- imaging when the surgical count is not reached.
static agent ultimately resorbs over the course of For example, cottonoids are compressed rayon
months. cotton pledgets or strips used for hemostasis,
Gelatin hemostatic agents, such as Surgifoam soft tissue protection, and tissue dissection that
and Gelfoam, are available in powder or sponge contain radiographically detectable markers
form. On CT, the sponge usually displays air (Fig. 4.43). Typically, cottonoids are not thrown
attenuation during the early postoperative period, off the field into a kick bucket when soiled as
but becomes higher attenuation as it absorbs are other larger sponges. Rather, they are kept
cerebrospinal fluid/blood, resulting in high T2 on the sterile field or discarded in a separate
and low T1 signal on MRI (Fig. 4.41), for exam- area to prevent them from being picked up with
ple. Eventually, the sponge resorbs and is no lon- larger sponges leading to incorrect counts.
ger apparent on imaging. Although gelatin foam Radiographs with at least two orthogonal views
hemostasis may incite varying degrees of granu- are usually sufficient for localizing retained
lomatous reaction, complications related to the surgical paraphernalia. Nevertheless, when
use of these agents are unusual. other metallic implants are intentionally pres-
Gelatin-thrombin matrix (Floseal) functions ent, the task can be more difficult, and CT may
as a sealant that acts at the end stage of the coag- be useful.
a b
c
d
Fig. 4.40 Oxidized regenerated cellulose. (a) Axial CT signal on T2-weighted (b), T1-weighted (c), and SWI (d)
image obtained after recent surgery shows globular low- sequences. Photograph of Surgicel (e) (Courtesy of
attenuation material with the right frontal lobe surgical Patricia Smith and Sarah Paengatelli)
cavity (arrow). The Surgicel (arrows) has relatively low
a b
Fig. 4.41 Gelatin foam. Axial CT image shows a folded about 1 month after surgery show the hemostatic agent
sheet of Gelfoam (arrow) deep to the craniotomy, which between the duraplasty and cranioplasty (arrows).
has higher attenuation than the surrounding pneumoceph- Photograph of Surgifoam (d) (Courtesy of Patricia Smith
alus but lower attenuation than the surrounding fluid. and Sarah Paengatelli)
Axial T2-weighted (b) and T1-weighted (c) MR images
a b
Fig. 4.42 Gelatin-thrombin matrix. Axial T2-weighed agent within the deep right cerebral (arrows), which has
(a), T1-weighted (b), and SWI (c) MR images show a developed blood clots
somewhat foamy appearance of the clustered hemostatic
a b
c
d
Fig. 4.43 Retained cottonoid. Immediately follow- in soft tissue (b) and bone (c) windows show the linear
ing resection of a large frontal meningioma, the neuro- metallic structures associated with the cottonoids left the
surgeons informed the radiologist that cottonoids were surgical bed (arrows) (Courtesy of Shehanaz Ellika MD).
left behind. Postoperative frontal radiograph (a) and CT Photograph of cottonoids (d) (Courtesy Jene Bohannon)
4.17 D
uraplasty and Sealant (Fig. 4.44). Associated dural enhancement can be
Agents seen in over 10% of cases. The dural regenerative
matrix intentionally resorbs at a similar rate as
4.17.1 Discussion the new tissue that forms, thus preventing encap-
sulation. Specifically, the collagen matrix typi-
Duraplasty consists of reconstructing the dura cally resorbs within 1–6 months, depending on
following cranial surgery in order to minimize the particular type.
cerebrospinal fluid leakage. Several dural substi- Polytetrafluoroethylene (Gore-Tex) sheets
tutes and sealant agents are commercially avail- appear as high attenuation on CT and very low
able, including bovine pericardium, elastin-fibrin, signal on T1-weighted and T2-weighted MRI
biosynthetic cellulose, polytetrafluoroethylene, sequences (Fig. 4.45). Small collections of cere-
and collagen matrix sheets, among others. brospinal fluid form adjacent to the duraplasty in
Some formulations of collagen matrix dura- 15% of cases. Often, thin membranes of granula-
plasty have a spongelike consistency, while oth- tion tissue form between the duraplasty and the
ers are more flat and compressed. These materials surface of the brain. In general, complications
appear as a low attenuation on CT and often of related to duraplasty procedures are infrequent
low-to-intermediate signal intensity on both and include graft failure with pseudomeningo-
T1-weighted and T2-weighted MRI sequences cele formation, epidural fibrosis, and infection.
a b
d
c
Fig. 4.44 Collagen matrix duraplasty. The patient has a post-contrast T1-weighted (c) MRI sequences show that
history of a large left frontal meningioma status post the duraplasty material (arrows) displays low T2 and
resection and duraplasty using DuraGen. CT image (a) intermediate T1 signal. Photograph of suturable DuraGen
shows the sheetlike low-attenuation duraplasty material (d) (Courtesy of Patricia Smith and Sarah Paengatelli)
(arrows) in the left frontal region. T2-weighted (b) and
a b
Fig. 4.45 Polytetrafluoroethylene (Gore-Tex) duraplasty. Coronal CT image (a) demonstrates high-attenuation dura-
plasty (arrow) after hemicraniectomy. On the T2-weighted MRI (b), the material (arrow) displays low signal
4.18 Intracranial Pressure tous fiber optic monitor enters the intracranial
Monitors cavity through a bolt that is introduced into a burr
hole (Fig. 4.46). Other devices for measuring
4.18.1 Discussion intracranial pressure include diaphragm-type
monitors and ventricular catheters with pressure
Conditions associated with raised intracranial sensors. Pressure monitors can be placed in the
pressure, such as hemorrhage, cerebral infarcts, or subarachnoid or subdural space, brain paren-
trauma, can compromise cerebral blood flow. A chyma, or ventricle. The components of the moni-
variety of intracranial pressure monitors are avail- tors are readily apparent on CT, allowing the
able, including fiber optic monitors. The filamen- precise position to be determined.
a b
Fig. 4.46 Intraparenchymal pressure monitor. The optic monitor enters the brain parenchyma (arrow).
patient has a history of severe traumatic brain injury Photograph of a Camino Bolt and pressure monitor and
resulting in a left subdural hematoma and intraparenchy- fiber optic (inset) (Codman Neuro New Brunswick NJ)
mal contusions. Sagittal CT image (a) shows the pressure (b) (Courtesy of Justin Hugelier)
bolt monitor seated in the burr hole through which a fiber
4.19 Subdural Drainage Catheters subdural collections to the skin surface can
reduce incidence of recurrence. Imaging can be
4.19.1 Discussion used to confirm the position of catheters and
assess changes in size of the hematomas. The
Chronic subdural hematomas can be treated via hyperattenuating catheters are readily apparent
burr hole evacuation. The use of drainage cathe- on CT (Fig. 4.47).
ters that extend through the burr holes from the
a b
Fig. 4.47 Subdural drainage catheter. Coronal CT images (a, b) show a catheter (arrows) extending from the subdural
space to an opening in the scalp
4.20 Cranial Surgery the lateral aspects of the bilateral frontal lobes
Complications are compressed together by the pressurized
intracranial air. Another related appearance is
4.20.1 Tension Pneumocephalus the “Mount Fuji” sign, which describes the com-
bination of compressed and separated frontal
Tension pneumocephalus following neurosur- lobes with widened interhemispheric space
gery is an uncommon but emergent condition. (Fig. 4.48). This sign is fairly specific for tension
Indeed, tension pneumocephalus can be life- pneumocephalus.
threatening since it can cause brainstem hernia- Ultimately, the diagnosis of tension pneumo-
tion. Possible risk factors include posterior fossa cephalus requires accompanying decline in clini-
craniotomy, the use of nitrogen oxide for anes- cal status manifesting as lethargy, a hissing noise
thesia, lumbar drainage, and cerebrospinal fluid during release of the pneumocephalus, and reso-
leakage, with dural defects that function as one- lution of symptoms thereafter. Treatment consists
way valves. of one or more of the following: 100% oxygen
A characteristic axial CT feature of tension supplementation, repair of dural defect, and burr
pneumocephalus is the “peaking” sign, in which hole decompression.
Fig. 4.48 Tension pneumocephalus. The patient pre-

sented with lethargy on postoperative day #3. Axial CT
image obtained after craniotomy shows extensive pneu-
mocephalus that compresses the bilateral frontal lobes and
lateral ventricles. There is separation of the frontal lobes
and a pointed appearance of the bilateral anterior frontal
lobes
4.20.2 Entered Frontal Sinus, uncommon and include mucoceles, cerebrospinal

Entered Orbit, and Air Leak fluid leak, and air leak with frontal sinus entry
and orbital hematomas and rectus muscle injury
The frontal sinus and orbits are entered in about with orbital entry. The presence of persistent
30% of craniotomies in adults, particularly via pneumocephalus or pneumo-orbit on serial CT
the pterional or orbitozygomatic approach. exams raises the suspicion of air leaks (Fig. 4.51).
However, these are usually noted during surgery High-resolution CT with multiplanar reconstruc-
and repair using fat graft and mesh (Figs. 4.49 tions is the first-line modality recommended for
and 4.50). Superimposed complications are assessing suspected cerebrospinal fluid leaks.
Fig. 4.49 Entered frontal sinus. Axial CT image demon-

strates a right frontal craniotomy that extended through
the right frontal sinus, which was obliterated with fat graft
a b
Fig. 4.50 Entered orbit. Coronal CT image (a) shows a defect in the left posterior orbital roof closed with fat graft
(arrow). Axial CT image (b) in a different patient shows entry of the left lateral orbit repaired with mesh (arrow)
a b
Fig. 4.51 Air leak. Axial (a) and coronal (b) CT images show left intraorbital air and proptosis after aneurysm clip-
ping. There is a defect in the superior orbital roof (arrow)
4.20.3 Postoperative Hemorrhage craniotomy site and may be caused by separa-

and Hematomas tion of the dura at the craniotomy margin, sud-
den collapse of the brain, or inferior extension
Small, asymptomatic hematomas are common of regional hemorrhage.
and can be considered an expected consequence • Remote intracranial hemorrhage is a relatively
of craniotomy and cranioplasty. Subgaleal hema- uncommon complication of intracranial sur-
tomas are ubiquitous in the early postoperative gery, comprising about 6% of extradural
period and are usually self-limited. Occasionally, hematomas. This type of hemorrhage may be
subgaleal hematomas can be voluminous and related to cerebrospinal fluid volume deple-
exert mass effect (Fig. 4.52). Similarly, postop- tion and decreased intracranial pressure and
erative intracranial hematomas can occasionally has a predilection for the cerebellum. Remote
cause symptoms such as altered mental status, cerebellar hemorrhage characteristically
neurological deficits, and seizures, which may appears as curvilinear high attenuation in the
require surgical evacuation. The variety of post- cerebellar sulci and folia on CT, which has
operative hematomas includes epidural (33%), been termed the “zebra sign.” Remote cerebral
subdural (5%), parenchymal (43%), or a combi- hemorrhages most commonly occur in the
nation of these (8%) and can be further classified frontal and then followed by the temporal
as regional, adjacent, or remote (Figs. 4.53, 4.54, lobe. These are most commonly related to the
4.55, and 4.56). Acute hematomas tend to be use of intraoperative retractors creating
hyperattenuating on CT, while chronic hemato- venous congestion leading to a hemorrhagic
mas evolve toward fluid attenuation. venous infarct. Hemorrhagic venous infarcts
can also be due to sacrificing crucial venous
• Regional hematomas are the most common structures.
and occur directly beneath the bone flaps. • Abdominal wall hematomas may result from
• Adjacent extradural hematomas are more storage of calvarial bone flaps for autocranio-
commonly posterior rather than anterior to the plasty (Fig. 4.57).
Fig. 4.53 Adjacent epidural hematoma. Axial CT image

shows lentiform high-attenuation extradural hematoma
(arrow) along the posterior margin of the craniotomy
Fig. 4.52 Subgaleal hematoma. Axial CT image shows a

hyperattenuation mass-like collection in the left scalp
overlying the craniotomy flap (arrow). There is also a
small amount of underlying extra-axial hemorrhage and
multiple cerebral infarcts
b
Fig. 4.54 Regional subdural hematoma. Axial CT image
shows a heterogeneous left subdural hematoma (arrow)
deep to the craniotomy flap
Fig. 4.55 Adjacent intraparenchymal hematoma. Preop

erative CT image (a) shows a large right frontal convexity
meningioma. Immediate postoperative CT image (b)
shows a large hyperattenuating hematoma subjacent to the
resection cavity. There is also extensive surrounding vaso-
genic edema
a b
c d
Fig. 4.56 Remote cerebellar hemorrhage. Axial CT MRI images in a different patient demonstrate curvilinear
image (a) in a patient who underwent supratentorial areas of subacute hemorrhage and edema in the bilateral
craniotomy shows crescentic hemorrhage in the bilat-
cerebellar hemisphere (arrows) following left temporal
eral cerebellar hemispheres. Axial T1-weighted (b), axial lobe tumor resection (arrowheads)
T2-weighted (c) and axial susceptibility-weighted (d)
Fig. 4.57 Axial CT

image shows a large
hematoma (*) subjacent
to the skull flap within
the subcutaneous
tissues
4.20.4 Postoperative Hygromas higher attenuation. Most hygromas are of little

and Effusions clinical significance, although some of these may
be associated with mass effect that may require
Hygromas develop in up to 60% of cases follow- additional decompressive surgery.
ing craniectomy, particularly decompressive cra- A particular complication related to posterior
niectomy for intracranial hypertension related to fossa tumor resection in pediatric patients is the
head trauma. Up to 90% of subdural hygromas formation of spinal subdural effusions. These
are ipsilateral to the craniectomy site. fluid collections result from sudden postoperative
Interhemispheric fissure subdural hygromas are normalization of the excessive intraspinal pres-
uncommon, as are subarachnoid hygromas. sure caused by spinal sequestration by tonsillar
Hygromas can also occur after craniotomy and herniation. On MRI, the effusions display T1 and
cranioplasty. T2 cerebrospinal fluid signal characteristics, but
Hygromas usually appear after 1 week of sur- can also enhance (Fig. 4.59). The collections also
gery, reach a maximum volume at 3–4 weeks, tend to have wavy margins and can compress the
and resolve over several months. On CT and spinal canal contents, thereby interfering with
MRI, hygromas appear as simple fluid collec- workup for metastatic disease. Otherwise, the
tions (Fig. 4.58). However, nearly 8% convert to collections are generally clinically silent and
subdural hematomas by 2 months, resulting in resolve within 1 month.
a b
Fig. 4.58 Subdural hygroma. Axial T2 (a) and T1 (b) MR images in a different patient show a cerebrospinal fluid
intensity collection along the left falx cerebri (arrows)
a b c d
Fig. 4.59 Postoperative intraspinal subdural effusions. images show postoperative findings related to suboccipi-
This pediatric patient underwent recent resection of a pos- tal cranioplasty and diffuse, but somewhat wavy, enhanc-
terior fossa medulloblastoma. Sagittal T1-weighted (a, b) ing subdural collections that compress the spinal canal
and fat-suppressed post-contrast T1-weighted (c, d) MR contents
4.20.5 Pseudomeningoceles Pseudomeningoceles often resolve spontaneously

as the dura seals over time and cerebrospinal fluid
Pseudomeningoceles represent contained cere- absorption returns to normal. However, when
brospinal fluid leakage or herniation of the sub- these are persistent or the suture line is under
arachnoid space through a defect in the dura. excess tension, exploration, repair, and/or cere-
Pseudomeningoceles are common postsurgical brospinal fluid diversion can be considered.
complications, especially in the suboccipital Persistent or enlarging cerebrospinal fluid collec-
region. On imaging, pseudomeningoceles appear tions near burr holes can sometimes reflect impair-
as simple fluid collections that bulge into the scalp ments in cerebrospinal fluid absorption, except in
or posterior cervical soft tissues and communicate infants, where cerebrospinal fluid can be extruded
with the intracranial space (Fig. 4.60). while crying and can get trapped extracranially.
a b
c d
Fig. 4.60 Suboccipital craniectomy pseudomeningocele. and axial (c) and sagittal (d) T1-weighted MRI sequences
Axial CT image (a) shows a large fluid collection at the show a fluid collection that follows cerebrospinal fluid
suboccipital craniectomy site (*). Axial T2–weighted (b) signal intensity (*) at the suboccipital craniectomy site
4.20.6 Pseudoaneurysm mass that appears as a hyperattenuating collec-

tion in the scalp on CT (Fig. 4.61). Angiography
Significant arterial injury resulting from retrosig- is recommended to ascertain the presence of a
moid craniotomy is an uncommon incident. pseudoaneurysm, which appears as an ovoid
Significant injury of the scalp arteries from cra- structure that enhances in parallel with the arter-
nial surgery is uncommon, but can lead to pseu- ies. Pseudoaneurysms can resolve spontaneously
doaneurysms. Patients can present with a pulsatile but may be amenable to endovascular therapy.
a b
Fig. 4.61 Postoperative occipital artery pseudoaneu- shows a large left occipital artery pseudoaneurysm
rysm. Axial CT image (a) shows hemorrhage overlying (arrow). The pseudoaneurysm was subsequently coiled,
the left retrosigmoid craniotomy site. CTA MIP image (b) as shown on a follow-up CT (c)
4.20.7 Postoperative Infection comprises over 40% of all infectious complica-

tions following craniotomy. The vast majority of
Infection is a serious complication of craniotomy, these cases are due to infection by Staphylococcus
craniectomy, and cranioplasty that can occur in aureus. Infected bone flaps may either demon-
the subgaleal, extradural, or subdural spaces strate areas of lucency or sclerosis on CT. These
within the bone flap and surrounding the cranio- findings are not specific for osteomyelitis and can
plasty (Figs. 4.62 and 4.63). The incidence is gen- be seen in normal bone flaps. However, the pres-
erally 4.5–6%, but varies depending upon the type ence of secondary changes, such as overlying
of material used. Staphylococcus aureus is the sinus tracts, skin thickening, fat stranding, and
most common responsible organism. The appear- adjacent fluid collections, should raise the suspi-
ance on CT is that of a fluid collection with cion of an infected bone flap. MRI can demon-
peripheral enhancement. MRI may show restricted strate increased T2 signal and decreased T1 signal
diffusion in the abscess. In addition, MR spectros- intensity within the infected bone flap marrow. In
copy may show elevated lactate. Although sys- addition, predisposing factors include communi-
temic signs of infection can be mild, management cation with the sinuses, multiple surgeries, long
consists of wound debridement, antibiotics, and intraoperative times, and surgery for preexisting
removal of the cranioplasty. Progressive increase intracranial infection. Treatment of bone flap
in size of the collection over time is a particularly osteomyelitis ranges from conservative manage-
suspicious finding. Osteomyelitis of bone flaps ment to bone flap removal.
a b
c d
Fig. 4.62 Infected craniotomy bed. Axial T2 (a), axial restricted diffusion within the intraparenchymal abscess
T1 (b), post-contrast axial (c), and coronal (d) T1 show on DWI (e) and ADC map (f) and abnormal signal in the
irregular fluid collections with rim enhancement in the left craniotomy flap due to osteomyelitis
parietal lobe and scalp overlying the craniotomy. There is
e f
Fig. 4.63 Infected cranioplasty prosthesis. The patient

presented with fever and pain at surgical site several
months after acrylic cranioplasty. Axial contrast-enhanced
CT image obtained 1 week later shows a biconvex fluid
collection surrounding the cranioplasty plate. Cultures
grew Staphylococcus aureus, and the cranioplasty mate-
rial was subsequently removed
4.20.8 Textiloma each agent exhibits distinctive morphologic fea-

tures that often permit specific identification, these
Resorbable and nonresorbable hemostatic agents typically consist of a core of degenerating hemo-
can incite foreign body reactions that appear mass- static agent surrounded by an inflammatory reac-
like and can mimic neoplasm or abscess. Various tion, which can demonstrate enhancement on
terms are used to describe this granulomatous imaging (Fig. 4.64). The presence of hemostatic
reaction, such as textilomas, gossypibomas, gau- material at the site of the lesion on baseline imag-
zomas, surgicelomas, and muslinomas. While ing, if available, can be a helpful clue.
a b
Fig. 4.64 Textiloma. Initial postoperative CT image (a) (c), and post-contrast T1-weighted (d) MR images show a
shows the hemostatic agent along the left planum sphenoi- well-defined lesion with peripheral enhancement (arrows)
dale (arrow). Follow-up axial T2-weighted (b), T1-weighted
4.20.9 Sunken Skin Flap Syndrome pressure. Large craniectomy defects predispose to
the development of sunken skin flap syndrome,
Sunken skin flap syndrome (syndrome of the tre- and brain atrophy accentuates the degree of con-
phined) is an uncommon, late complication of cavity. This condition is certainly not cosmeti-
craniectomy, usually occurring 1 month after sur- cally pleasing and may even compromise cerebral
gery. This complication consists of depression of blood flow. Furthermore, along with headache,
the scalp flap and brain deformity at the site of fatigue, and seizure, sunken skin flaps may be a
craniectomy (Fig. 4.65). The cause is presumed to manifestation of trephine syndrome. These out-
be atmospheric pressure that exceeds intracranial comes often improve following cranioplasty.
a b
Fig. 4.65 Sunken flap syndrome. Axial (a) and coronal (b) CT images show severe concavity of the scalp contours at
the craniectomy site. There is no associated brain herniation
4.20.10 External Brain Herniation
Following craniectomy for cerebral edema, extra-

cranial herniation of the brain occurs in over 25%
of cases. Although some degree of brain expan-
sion is expected after craniectomy, extension of
brain tissue beyond 1.5 cm measured at the center
of the osseous defect with respect to the outer
table of the calvarium is generally considered
abnormal. Extracranial cerebral herniation is
more likely to occur with small craniectomy
defects. This can produce a characteristic “mush-
room cap” appearance of the deformed brain tis-
sue (Fig. 4.66). The herniated brain tissue is
particularly susceptible to trauma. Extracranial
herniation can also lead to venous infarcts sec-
ondary to cortical vein compression. This risk of
substantial external brain herniation is lower with
larger craniectomies. Fig. 4.66 External brain herniation. Axial CT shows
substantial herniation of the intracranial contents through
the left craniectomy defect with a “mushroom cap”
appearance posteriorly
4.20.11 Bone Flap Resorption plates, and sunken scalp syndrome may ensue.
Alternatively, intracranial contents can herniate
Although mild remodeling of the bone flap edges through the defects. On CT, bone flap resorption
over time is expected and of no consequence, appears as tapered edges and wide gaps between
severe bone flap resorption can be problematic. the calvarium (Fig. 4.67). These patients can ben-
This is a delayed complication that occurs in efit from artificial cranioplasty, and high-resolu-
6–12% of cases. As resorption progresses, the tion 3D CT is particularly helpful for surgical
bone flap becomes detached from the securing planning subsequent repair.
a b
Fig. 4.67 Bone flap resorption. Coronal CT (a) and 3D flap and the rest of the calvarium. Consequently, some of
CT (b) images demonstrate thinning of the right frontal the cranial plates are not fully anchored to bone
bone flap edges with wide gaps between the craniotomy
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stimulation for treatment of intractable occipital neu- (2010) Free flap options for reconstruction of compli-
ralgia. Neurosurgery 58(1):112–119; discussion cated scalp and calvarial defects: report of a series of
112–119 cases and literature review. Microsurgery 30(1):13–18
Guerrissi JO (1999) Reconstruction of large defects in the
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Imaging the Intraoperative
and Postoperative Brain 5
Daniel Thomas Ginat, Pamela W. Schaefer,
5.1 Intraoperative MRI of oxyhemoglobin. On susceptibility- weighted

sequences, hyperacute intraparenchymal hemato-
5.1.1 Discussion mas tend to appear hyperintense centrally with a
thin rim of dark signal. Extraparenchymal hyper-
The main goal of using MRI during brain tumor acute hemorrhage tends to be of intermediate
resection is to safely maximize the extent of tumor signal on T1-weighted sequences, but conspicu-
resection. In particular, imaging during surgery ously hyperintense on T2-FLAIR MRI (Fig. 5.2).
can also help compensate for the brain shift, which Hemostatic agents can mimic hemorrhage or
represents surgically induced volumetric defor- residual enhancing tumor due to the rapid T1
mation of the intracranial contents attributable shortening effect on blood products. Serial post-
to resection of the tumor, as well as intracranial contrast T1-weighted images can be useful for
pressure changes that result from craniotomy and depicting residual enhancing tumor. A potential
cerebrospinal fluid (Fig. 5.1). Intraoperative MRI confounder is the presence of contrast leakage at
is also useful for identifying complications during the margins of the resection cavity, which tends to
surgery that might require intervention, such as appear more diffuse than nodular (Fig. 5.3).
hyperacute intracranial hemorrhage. Hyperacute Laser interstitial thermal therapy comprises
intraparenchymal hemorrhage typically appears various minimally invasive procedures that are
as isointense to the surrounding parenchyma increasingly used to treat selected brain tumors,
on T1-weighted sequences, but hyperintense neuropsychiatric disorders, and epileptogenic
on T2-weighted sequences due to the presence foci. MRI is also useful for real-time monitor-
ing of these thermal ablation procedures. In
particular, MR thermography, which can exploit
D.T. Ginat, M.D., M.S. (*) phase shifts of protons at different temperatures,
University of Chicago, Pritzker School of Medicine, can provide a temperature map during ablation
Chicago, IL, USA and from which an irreversible damage model
can be derived based on the treatment duration
P.W. Schaefer, M.D. (Fig. 5.4). Besides coagulative necrosis, a small
Department of Neuroradiology, Harvard Medical
School, Massachusetts General Hospital,
amount of hemorrhage and transient swell-
Boston, MA, USA ing commonly result from thermal ablation
M.D. Moisi, M.D., M.S.
(Fig. 5.5). However, an increase in lesion size,
Department of Neurosurgery, Swedish Neuroscience heterogeneity, p eripheral nodular enhancement,
Institute, Seattle, WA, USA restricted diffusion, elevated blood volume,

DOI 10.1007/978-3-319-52341-5_5
and surrounding edema that persists or devel- into gliosis; a peripheral zone with low T1 and
ops after one or 2 months following treatment high T2 signal due to additional edema, which
should raise the suspicion for tumor recurrence ultimately resolves; and a central zone sur-
(Fig. 5.6). Otherwise, thermal ablation results in rounding the probe tract with high T1 and low
a predictable progression of signal changes on T2 signal due to the presence of blood prod-
MRI. In particular, MRI of recently thermally ucts and coagulative necrosis, which persists
ablated lesions displays a marginal zone with amidst encephalomalacia. Some of these find-
low T1 and high T2 signal due to edema with ings are exemplified in subsequent sections of
rim enhancement, which eventually transforms this chapter.
a b
Fig. 5.1 Brain shift. Preoperative FLAIR image (a) the lesion and a change in the overall morphology of the
shows a hyperintense lesion in the right frontal lobe. surrounding right frontal lobe parenchyma
Intraoperative FLAIR image (b) shows partial resection of
5 Imaging the Intraoperative and Postoperative Brain 185
a b
Fig. 5.2 Enhancing tumor resection and contrast leak- (arrow), which represented residual tumor. Axial post-
age. Initial axial post-contrast T1-weighted image (a) contrast T1-weigthted MRI (c) obtained after further
shows a peripherally enhancing left temporal lobe glio- resection shows that there are no longer residual enhanc-
blastoma. Axial post-contrast T1-weigthted MRI (b) ing tumor components. Faint enhancement along the mar-
obtained after the first resection attempt shows a punctate gins of the resection cavity represents contrast leakage
focus of nodular enhancement in the medial resection bed (arrowheads)
a b
Fig. 5.3 Hyperacute hemorrhage and hemostatic mate- hematoma with intermediate T1 and high T2 signal
rial. Axial T1- (a) and T2-FLAIR (b) intraoperative MR (arrows). The hemostatic agent in the extradural space
images obtained at the end of right frontal lobe tumor along the right frontal convexity surgical bed displays
resection show a small left parietal convexity subdural high T1 and T2 signal (arrowheads)
Fig. 5.4 Laser ablation. MR thermography performed during ablation of the right hippocampus shows real-time tem-
perature monitoring and irreversible damage model (Courtesy of Amy Schneider, Medtronic)
a b
Fig. 5.5 Transient tumor swelling after laser ablation. when the patient developed memory formation difficulties
Preoperative coronal T2-weighted MRI (a) shows a shows increase in size of the tumor (arrows) and lateral
hyperintense hypothalamic tumor, which proved to be a ventricles. Follow-up coronal T2-weighted MRI (c) after
pilocytic astrocytoma (arrow). The coronal T2-weighted steroid taper shows interval decrease in size of the tumor
MRI (b) obtained 1 week after laser ablation of the tumor (arrow) and lateral ventricles
a b
Fig. 5.6 Tumor progression after laser ablation. T1-weighted MRI (b) obtained over 1 month after laser
Preoperative axial T1-weighted MRI (a) shows a homo- ablation shows central necrosis, but overall increase in
geneously enhancing right midbrain tumor. Axial size of the enhancing tumor
5.2 rain Tumor Surgery

B (Fig. 5.7). In addition, the blood products left
and Treatment Accessories along the biopsy path that are apparent on MRI
can also serve as a useful indicator of whether the
5.2.1 Stereotactic Biopsy lesion was appropriately sampled. Nevertheless,
some operators prefer to insert a metal marker
5.2.1.1 Discussion in the biopsy cavity as a reliable indicator that is
Stereotactic biopsy is an image-guided proce- visible on imaging (Fig. 5.8). Although off-target
dure that is commonly performed to obtain tissue biopsy can yield tumor cells if the lesion is an
samples of intracranial lesions. Hemorrhage is infiltrative tumor, the grade may be underesti-
one of the most common findings after stereotac- mated. Ideally, biopsy of the enhancing portion of
tic brain biopsy, occurring in up to 9% of cases. the tumor with the highest cerebral blood volume
Hemorrhage along the biopsy trajectory has a (CBV) on perfusion-weighted MRI should be
characteristic linear configuration. Small amounts performed. Another uncommon, but notable com-
of blood products along the path of the biopsy plication of stereotactic biopsy is tumor seeding
that may only be discernible on T2* GRE or (Fig. 5.9). Otherwise, a mild degree of enhance-
SWI sequences are usually of no clinical concern ment in the brain parenchyma along the biopsy
and resolve spontaneously. Rather, such findings path is often encountered on early postoperative
serve to delineate the path of the biopsy needle imaging as an incidental finding that typically
and can help account for new neurological d eficits resolves within a couple of months (Fig. 5.10).
Fig. 5.7 Blood products along the path of biopsy. The

patient experienced new right-sided abducens palsy after
right transfrontal biopsy of a medulla lesion. Axial SWI
shows susceptibility effect along the expected location of
the right abducens nucleus/nerve (arrow)
Fig. 5.8 Biopsy cavity marker. Axial CT image shows a

titanium clip (arrow) deposited in the right thalamocapsu-
lar junction biopsy site, not to be mistaken for hemorrhage
or an unintended foreign body
Fig. 5.9 Tumor seeding. Axial post-contrast T1-weighted

MRI shows necrotic tumors (arrows) in the right temporal
fossa, near the surgical approach in a patient with renal
cell carcinoma that had metastasized to the brain
a b
Fig. 5.10 Expected biopsy path enhancement. Initial post-contrast T1-weighted MRI (b) obtained 3 months
coronal post-contrast T1-weighted MRI (a) obtained soon later shows that the enhancement has resolved, leaving
after left transfrontal biopsy shows enhancement along behind a small area of low signal due to encephalomalacia
the path of the biopsy needle (arrow). Follow-up coronal (arrow)
5.2.2 Resection Cavities on several factors, including the location and type
of tumor. Tumors that involve eloquent parts of
5.2.2.1 Discussion the brain, that are in technically difficult areas
The space that remains after a tumor is surgically to reach, or that involve critical structures, such
removed is known as the resection cavity. The as cranial nerves or major arteries, can limit the
resection cavity is often lined or packed with extent of tumor resection. Similarly, it is more
hemostatic agents (refer to Chap. 4) and contains difficult to achieve complete resection of infiltra-
variable amounts of cerebrospinal fluid and blood tive tumors than well-defined tumors. Ultimately,
products, especially during the early postopera- there is often a trade-off between removing as
tive period (Fig. 5.11). Oftentimes, resection much tumor as possible versus preserving as
cavities eventually shrink and collapse, becom- much normal tissue and avoiding complications.
ing nearly imperceptible (Fig. 5.12), although Comparison with preoperative imaging should be
some cavities stay the same size, particularly if performed when possible to help identify resid-
they communicate with the ventricular system. ual tumor.
Variable amounts of tumor may remain adja- Surgically induced parenchymal injury, post-
cent to the cavity depending on whether gross operative hemorrhage, and enhancing conditions
total, near-total, or subtotal resection was per- related to brain tumor surgery and adjunctive
formed. The extent of tumor resection depends treatments are discussed in the following sections.
a b
Fig. 5.11 Early surgical cavity with blood products. blood products within a right temporal resection cavity
Axial FLAIR (a), T1-weighted (b), post-contrast (arrows). There is no significant mass effect or
T1-weighted (c), and GRE (d) MR images show subacute enhancement
c
d
Fig. 5.12 Resection cavity evolution. Initial postopera-

tive axial T2-weighted MRI (a) shows a fluid-filled resec-
tion cavity in the right parietal lobe (arrow). Axial
T2-weighted MRI obtained 7 months later (b) shows near-
complete collapse of the resection cavity (arrow)
Surgically Induced Parenchymal Injury A peculiar complication related to posterior

Local areas of devitalized brain tissue surround- fossa tumor resections is hypertrophic olivary
ing the resection cavity are encountered on early degeneration, which results from disruption of
postoperative MRI in up to 70% of cases of high- the dentato-rubro-olivary pathway (Guillain-
grade glioma resection as well as many other Mollaret triangle). This phenomenon can occur
tumor resections. This phenomenon manifests after surgical resection of cerebellar tumors. If
as focal areas of restricted diffusion (Fig. 5.13). the resection site involves the central tegmental
Enhancement of the devitalized tissue occurs tract, the ipsilateral olivary nucleus is affected,
in over 40% of cases between 1 week and sev- while if the superior cerebellar peduncle is
eral months. Furthermore, this phenomenon can involved, the contralateral olivary nucleus is
lead to overestimation of residual non-enhancing affected. Thus, bilateral hypertrophic olivary
tumor volume due to the presence of swelling and degeneration results from disruption of the cen-
high signal on T2-weighted sequences during the tral tegmental tract and superior cerebellar
early postoperative period. Visible encephaloma- peduncle. Tongue fasciculations are characteris-
lacia eventually forms around the surgical cavity tic of hypertrophic olivary degeneration. On
in over 90% of cases of resection site infarcts. MRI, hypertrophic olivary degeneration mani-
Larger, territorial infarcts are uncommon compli- fests as T2 hyperintensity with or without
cations of tumor resection, but are predisposed enlargement of the anterolateral medulla
by proximity to or encasement of major arterial (Fig. 5.15). The differential diagnosis includes
branches and occasionally venous occlusion. ischemia, demyelination, tumor spread, and
Vasogenic edema can result from forceful infection. The lack of enhancement with hyper-
intraoperative retraction, which is sometimes trophic olivary degeneration may help differenti-
performed in order to access large or deep tumors. ate this entity from the other possibilities, such as
The edema may be related to hyperemia of the some neoplasms. In addition, most cases demon-
brain surface after the release of retraction. On strate associated atrophy of the contralateral den-
imaging obtained during the early postoperative tate nucleus or cerebellar cortex. Signal changes
period, retraction-induced vasogenic edema on MRI develop approximately 1 month after
appears as swelling along the path of the retrac- surgery and can persist for many years.
tors (Fig. 5.14). Unlike acute infarction, the vaso- Hypertrophy of the olivary nucleus tends to
genic edema demonstrates elevated diffusivity develop after several months and can resolve
rather than restricted diffusion. after 2–3 years.
a b
Fig. 5.13 Peri-resection infarction. The patient under- maps show an area of restricted diffusion posterior to the
went recent resection of a right posterior temporal lobe resection cavity (arrows)
glioblastoma. Axial FLAIR (a), DWI (b), and ADC (c)
a b
c
d
Fig. 5.14 Retraction-induced vasogenic edema. The of hyperintensity in the bilateral medial cerebellar hemi-
patient has a history of fourth ventricular medulloblas- spheres. The diffusion-weighted image (c) and ADC map
toma. Preoperative axial FLAIR image (a) shows a large (d) show corresponding mildly elevated diffusivity
fourth ventricular mass, but no surrounding vasogenic (arrows). Small areas of ischemia are also present
edema. Postoperative FLAIR image (b) shows new areas medially
a b
Fig. 5.15 Hypertrophic olivary degeneration. The patient shows the resection site (encircled). Axial FLAIR MRI
presented with tongue fasciculations after resection of a (b) shows high signal within an enlarged left olivary
right pontine cavernous malformation. Axial T2 MRI (a) nucleus (arrow)
Postoperative Hemorrhagic Lesions Chronic hemorrhage after surgery can result in

Hemorrhage is a relatively common occurrence superficial siderosis and mainly occurs when there
with tumor resection and usually occurs at the cra- is a cystic cavity that contains friable vessels or
niotomy site. CT or MRI can readily depict these residual/recurrent tumor (Fig. 5.18). Hemosiderin
hemorrhages. The lack of contrast enhancement deposits can coat remote leptomeningeal surfaces,
and susceptibility effects help distinguish particularly the cerebellum and brainstem. On CT,
hematomas from residual tumor (Fig. 5.16). superficial siderosis can appear as a mildly hyper-
Hemorrhage that results from incomplete tumor attenuating coating of these structures, which
resection is sometimes termed “wounded tumor may also become atrophic as a result. MRI is
syndrome” and is more commonly encountered more sensitive for depicting hemosiderin depos-
with vascular tumors, such as melanoma, renal its, which appear as very low signal intensity on
cell carcinoma, and glioblastoma (Fig. 5.17). all sequences. Blooming artifact on T2* GRE or
Other risk factors for postoperative hemorrhage SWI sequences accentuates the lesions. The sig-
include inadequate hemostasis, underlying coag- nificance of superficial siderosis is that it may
ulopathies, and hypertension. cause symptoms such as ataxia and deafness.
a b
c d
Fig. 5.16 Operative bed hemorrhage. The study was images show an intrinsically T1 hyperintense and T2
obtained to evaluate for residual tumor following recent hypointense extradural collection (*) with blooming and
meningioma resection. Copious oozing of blood was mass effect upon the underlying brain. There is also a
noted during surgery. Axial T1-weighted (a) and post- small amount of hemorrhage within the surgical cavity
contrast T1-weighted (b), T2-weighted (c), and GRE (d) associated with hemostatic material (arrows)
a b
c d
Fig. 5.17 Wounded tumor. The patient underwent subtotal and susceptibility-weighted imaging (d) show interval
resection of glioblastoma. Preoperative axial T1-weighted appearance of high T1 signal hemorrhage and extensive
(a) and susceptibility-weighted imaging (b) show a large susceptibility effect within and adjacent to the residual
mass (*) in the left frontal lobe with only a few foci of tumor (arrows)
microhemorrhage. Postoperative axial T1-weighted (c)

a b
Fig. 5.18 Superficial siderosis. Axial T2-weighted MRI margins of the cavity and along the cerebral sulci. SWI
(a) and corresponding SWI (b) show a cystic left fron- at a more inferior level (c) shows extensive susceptibil-
tal lobe resection cavity with layering of blood products ity effect in a leptomeningeal distribution in the brainstem
(arrows). In addition, there is blooming effect along the and cerebellum
Enhancing Lesions in the Surgical Bed such as perfusion MRI and MR spectroscopy, are
Region and Beyond often helpful for problem solving. Nevertheless, in
Many types of enhancing lesions can be encoun- some cases, biopsy or serial imaging can help elu-
tered on imaging after surgery, as listed in Table 5.1 cidate ambiguous cases. It is also important to sys-
and depicted in Figs. 5.19, 5.20, 5.21, 5.22, and tematically evaluate the areas beyond the surgical
5.23. Indeed, several of these conditions can coex- bed on imaging exams, particularly with aggres-
ist and make interpretation of the imaging a chal- sive neoplasms, such as glioblastoma, which can
lenge. Differentiation of these conditions from undergo spread to remote parts of the brain, seed
recurrent enhancing tumor is based on morphology the scalp and face soft tissues, and undergo cere-
as well as timing. Advanced imaging techniques, brospinal fluid dissemination.
Table 5.1 Differential diagnosis of enhancing lesions on MRI after treatment for malignant glioma (Courtesy John
W. Henson, MD and Jennifer Wulff, ARNP)
Condition Onset Other features
Granulation tissue First postoperative week The enhancement is typically linear and smooth, but can
(usually after 2 or 3 days), become more nodular by 1 week following surgery. Since
intensifies over the ensuing residual enhancing tumor can be obscured or confounded by
weeks, and resolves over granulation tissue, baseline imaging is recommended within
3–5 months 48 h of surgery, before granulation tissue forms. Serial imaging
can also help to differentiate granulation tissue from residual
tumor in that tumor increases in size over time, while
granulation tissue should remain stable and eventually resolves
Perioperative 2 weeks after surgery Two-thirds of patients have focal infarcts around the resection
ischemia cavity, and this can account for new post-op neurological
deficits. Look for this on immediate post-op DWI. Can enhance
after 10–14 days. Enhancement slowly resolves, leaving an area
of encephalomalacia
Postoperative 1–3 weeks after surgery Clinical deterioration and new enhancement 1–3 weeks after
infection surgery should raise a question of infection. Wound breakdown
and drainage, markedly tender wound, fever, and elevated ESR
can occur. Focal infection may show restricted diffusion
Pseudoprogression Within 3 months following Inflammatory response to treatment. Often symptomatic.
completion of concomitant Occurs within the RT port. Cannot be distinguished from true
RT and TMZ progression by either routine MRI or advanced* MRI or
FDG-PET. More likely in glioblastoma with methylated
MGMT promoter. Wanes with time (scans are performed every
month until change determines likely diagnosis). Good
prognostic factor
True progression Any time following Worsens with time. Routine MRI cannot distinguish from
surgery pseudoprogression and radiation necrosis, but tumor tends to
have elevated blood volume on perfusion MRI. More likely in
tumors without methylation of the MGMT promoter. Poor
prognostic factor
Radiation necrosis Usually >1 year after Routine MRI cannot distinguish from progression; advanced
radiation therapy MRI and FDG-PET can be very useful in distinguishing from
progression. Can progress or wane over time. SMART
(stroke-like migraines after radiation therapy) syndrome is an
unusual, late complication of localized radiation therapy for
brain tumors, in which patients present with headache and
neurological deficits between about 2 and 10 years after
treatment, usually greater than 50 Gy of radiation. Treated with
observation, steroids, bevacizumab, or surgery
Fig. 5.19 Granulation tissue. The patient is status post

meningioma resection 5 days prior to imaging. Coronal
post-contrast T1-weighted MRI shows a thin circumfer-
ential rim of enhancement along the resection margin
(arrow)
a b
Fig. 5.20 Perioperative infarct. Pre- (a) and post-contrast tissues enhance (arrow). Furthermore, the CBV map (c)
(b) T1-weighted MR images obtained 1 month after sur- shows corresponding hypoperfusion in the area (arrow)
gery in the same case as in Fig. 5.13 show that the infarcted
a b
c d
Fig. 5.21 Tumor progression. The patient underwent 1 year later show a new focus of enhancement adjacent to
gross total resection of an oligoastrocytoma (WHO grade the resection cavity (arrow), but no obvious change in the
II/IV) in the right frontal lobe. Axial FLAIR (a) and post- FLAIR signal abnormality. Axial FLAIR (e), post-con-
contrast T1-weighted (b) MR images obtained approxi- trast T1-weighted (f), subtraction image (g), and CBV
mately 10 years after resection show a right frontal map (h) obtained approximately 6 months later demon-
resection cavity surrounded by non-enhancing FLAIR strate marked interval increase in volume of the FLAIR
signal abnormality. Axial FLAIR (c) and post-contrast signal abnormality and enhancing adjacent to the resec-
T1-weighted (d) MR images obtained approximately tion cavity and associated elevated CBC (arrows)
e f
g h
a c
b
a b
Fig. 5.23 Metastatic glioblastoma in the spinal canal. involving the bilateral frontal lobes, extending to the men-
The patient presented with back and low extremity pain ingeal surface. Sagittal post-contrast T1-weighted MRI
after gross total resection of a left frontal glioblastoma (b) shows an intradural, extramedullary mass with irregu-
resection with recurrence. Sagittal post-contrast lar enhancement in the upper lumbar spinal canal (arrow)
T1-weighted MRI (a) shows irregular enhancement
Fig. 5.22 Radiation necrosis. The patient has a history of corresponding hypermetabolism on the blood volume
left frontal lobe glioblastoma that was resected and map (b). MRI spectroscopy (c) over the abnormality
radiated approximately 1 year before. Axial (a) post-
shows a lactate peak, mildly reduced NAA peak, and a
contrast T1-weighted MRI shows small areas of enhance- Cho peak that is not particularly elevated with respect
ment in the treatment bed region (arrows). There is no to Cr
5.2.3 Ommaya Reservoirs (simple fluid collections), which can also occur
with Ommaya catheter placement. Management
5.2.3.1 Discussion consists of antibiotic therapy and possible hard-
Intrathecal chemotherapy can lengthen survival ware removal and debridement depending on the
and alleviate symptoms in patients with wide- extent of the infection.
spread leptomeningeal metastases. The two Focal brain necrosis due to chemotherapy
primary means of delivering intrathecal chemo- extravasation secondary to Ommaya reservoir
therapy are Ommaya reservoirs and repeat lum- catheter obstruction is rare, with an incidence
bar puncture. Ommaya reservoirs are implanted of 0.6% of patients. This condition is caused by
in the subcutaneous tissues of the scalp and con- displacement of the catheter tip into the brain
tain a pump mechanism for drug delivery agents parenchyma. Imaging demonstrates circumfer-
into the ventricular system through an intraven- ential areas of necrosis surrounding the retracted
tricular catheter (Fig. 5.24). Ommaya reservoirs Ommaya catheter, manifesting as patchy enhance-
offer many advantages over repeat lumbar punc- ment, high T2 signal, and restricted diffusion, rep-
tures, including greater patient comfort, dimin- resenting cytotoxic edema (Fig. 5.26). A unique
ished risk for patients with thrombocytopenia, and serious complication of methotrexate extrav-
more consistent drug levels, and possibly greater asation is progressive leukoencephalopathy. This
clinical efficacy. Tumor cyst devices are similar entity involves the white matter diffusely and can
to Ommaya shunts, but are used to inject chemo- be either hemorrhagic or nonhemorrhagic.
therapeutic agents directly into tumors. Cerebrospinal fluid cysts can sometimes form
Infection is a major complication of Ommaya around Ommaya catheters and may be caused
catheter placement. The incidence of Ommaya- by distal shunt obstruction, although this com-
associated infection is 15% within the first year of plication can also occur when the catheter is
placement (range 2–23%). Staphylococcus aureus appropriately positioned, with or without hydro-
and Staphylococcus epidermidis are the most cephalus. The pericatheter cysts do not have
common causative organisms. Manifestations of perceptible walls or rim enhancement, but may
catheter-associated infection range from menin- have surrounding edema. Although the cysts may
gitis to abscess, for which imaging is useful for be asymptomatic, it is important to evaluate for
identifying fluid collections surrounding the cath- predisposing factors that could be addressed,
eter (Fig. 5.25). Debris in the fluid and enhance- such as malpositioning of the Ommaya catheter
ment helps differentiate infection from hygromas (Fig. 5.27).
a b
Fig. 5.24 Ommaya reservoir components. The patient ment via a burr hole. The tip of the catheter lies within the
has a history of leptomeningeal spread of breast cancer. anterior horn of the left lateral ventricle (b). 3D CT image
Axial CT images show the Ommaya reservoir (arrow) (c) shows the reservoir (arrows) and catheter entering the
positioned in the right frontal subcutaneous tissues (a). skull through a burr hole
The drug delivery catheter enters the intracranial compart-
a b
c d
Fig. 5.25 Ommaya catheter infection. The patient pre- T2-weighted (b), T1-weighted (c), and post-contrast
sented with exposed Ommaya reservoir hardware and cel- T1-weighted (d) MR images show a complex fluid collec-
lulitis. Axial CT image (a) shows a left parietal Ommaya tion with rim enhancement surrounding the Ommaya
catheter surrounded by a fluid collection (arrow), which is catheter, compatible with a pericatheter abscess
difficult to discern amidst streak artifact. Axial
a b
Fig. 5.26 Extravasation of methotrexate through blocked better delineates the extent edema surrounding the
Ommaya reservoir with focal brain necrosis. Post-contrast Ommaya catheter, and the corresponding ADC map (c)
sagittal T1-weighted MRI (a) shows edema and patchy shows restricted diffusion surrounding the path of the
enhancement surrounding the catheter. Axial FLAIR (c) Ommaya catheter, consistent with cytotoxic edema
a b
Fig. 5.27 Ommaya catheter-associated cyst and catheter MRI (b) shows the catheter (arrow) has penetrated the
malpositioning (a) shows a right frontal lobe periventricu- right basal ganglia instead of the lateral ventricle. There is
lar cerebrospinal fluid cyst (encircled). Axial T1-weighted also hydrocephalus
5.2.4 Chemotherapy Wafers The presence of wafers does not alter the
pattern of tumor recurrence. Perfusion MRI
5.2.4.1 Discussion is particularly useful to monitor the treatment
Chemotherapy wafers, such as carmustine effects and differentiate these from recurrent neo-
implants (Gliadel), are sometimes implanted in the plasm. The presence of foci with elevated CBV
surgical bed after malignant brain neoplasm resec- suggests tumor recurrence. MR spectroscopy can
tion. The wafers are biodegradable sheets of poly- also be useful for monitoring tumor response to
mers that are impregnated with the chemotherapy chemotherapy wafers. For example, it has been
agent. Initially, the wafers appear as hypointense noted that increased peritumoral NAA/Cr and
linear structures on T1- and T2-weighted MRI decreased peritumoral Cho/NAA compared with
sequences, but they can change in signal intensity normal brain tissue by 3–5 weeks suggest treat-
characteristics over time (Fig. 5.28). ment response.
a b
Fig. 5.28 Chemotherapy wafers. The patient has a his- tion cavity (arrows). T2-weighted (b) and axial
tory of glioblastoma status post resection and implanta- T1-weighted (c) MR images obtained 1 day after surgery
tion of Gliadel wafers. Axial CT (a) shows hyperattenuating demonstrate the low signal linear Gliadel wafers (arrows)
linear structures along the edges of the right frontal resec- lining the resection cavity
5.2.5 Brachytherapy Seeds be implanted temporarily (for approximately

1 week) or permanently. Temporary seeds are
5.2.5.1 Discussion typically introduced and removed using plastic
Local radiation therapy can be administered for catheters passed through burr holes, while per-
treatment of brain tumors via brachytherapy manent seeds are implanted in the tumor/surgical
(interstitial) seed implantation. The seeds con- bed. The seeds appear as tiny metallic cylinders
tain radioactive isotopes, such as I-125, and can on CT or signal voids on MRI (Fig. 5.29).
a b
Fig. 5.29 Brachytherapy seeds. The patient has a history CT image (a) demonstrates numerous metallic interstitial
of metastatic sarcoma to the right frontal lobe and is status seeds each measuring a few millimeters in length within the
post right frontal craniotomy, gross total tumor resection, surgical cavity. On both T2-weighted (b) and T1-weighted
and placement of I-125 interstitial radiation seeds. Axial (c) MRI, the seeds are of low signal intensity
5.2.6 GliaSite Radiation positioned within the surgical cavity. The filled
Therapy System balloon is hyperattenuating on CT and displays
fluid signal on MRI (Fig. 5.30). Normally, there
5.2.6.1 Discussion can be enhancement in the tissues surrounding
The GliaSite radiation therapy system is used the balloon. The catheter and its position mark-
to administer intracranial brachytherapy for ers are also visible on both modalities. However,
brain tumor treatment. The system is a catheter- the balloon and surrounding tissues are better
based device that consists of an infusion port assessed on MRI, particularly when there is
on one end and a double balloon on the other. tumor recurrence. Perfusion MRI is especially
Positioning markers are also included along helpful for evaluating enhancing lesions in the
the length of the catheter. The balloon, which tumor bed, whereby elevated rCBV suggests
contains the radioactive isotope solution, is recurrence of high-grade tumor.
a b
Fig. 5.30 GliaSite system. The patient has a history of post-contrast (e) T1-weighted images and CBV map (f)
right frontal glioblastoma, status post resection. Axial obtained 1 year later show an enhancing nodule with cor-
CT (a) and axial T2-weighted (b) and T1-weighted (c) responding increased perfusion adjacent to the catheter in
MR images that show the fluid-filled GliaSite radia- the surgical bed, consistent with recurrent tumor (arrows).
tion therapy system balloon at the end of the low signal Illustration of the GliaSite Radiation Therapy system (g)
intensity catheter with positioning markers. Pre- (d) and
c d
e f
5.3 Neurodegenerative, as the leukotome via a transorbital or transcra-

Neuropsychiatric, nial approach. This produces the appearance
and Epilepsy Surgery of band-like cavitary lesions in the frontal
lobe white matter (Fig. 5.31). On MRI, FLAIR
5.3.1 Prefrontal Lobotomy sequences show a hyperintense rim of gliosis
surrounding the c avitary defects. Focal atrophy
5.3.1.1 Discussion of the frontal lobe and corpus callosum is com-
Prefrontal lobotomy (leucotomy) is a now mon and often pronounced. High-attenuation
obsolete procedure that was introduced in 1935 foci on CT and susceptibility effects on MRI
as a treatment option for psychiatric illnesses, can be observed along the lobotomy margins,
such as schizophrenia. The procedure essen- which correspond to residual Pantopaque used
tially consists of ablating the frontal lobe white for visualization of the lobotomy plane during
matter tracts using a probe-like device known the operation.
a b
Fig. 5.31 Bilateral prefrontal lobotomy. The patient has the bilateral frontal lobe sulci. Axial FLAIR (c), axial
a history of schizophrenia treated with bifrontal lobotomy T1-weighted (d), and sagittal T1-weighted (e) MR images
many years before. Axial (a) and coronal (b) CT images demonstrate linear cystic defects in the bilateral frontal
show low-attenuation defects in the bilateral frontal lobe lobes with surrounding white matter signal abnormality,
white matter. There are scattered punctate hyperattenuat- consistent with gliosis. Axial GRE (f) shows small foci of
ing foci in the surgical defects bilaterally, consistent with susceptibility, which correspond to residual deposits of
Pantopaque. There is also disproportionate enlargement of Pantopaque (arrows)
c d
e f
5.3.2 Pallidotomy a
5.3.2.1 Discussion
Pallidotomy is a procedure that can be performed
in Parkinson’s disease patients who do not expe-
rience adequate symptom relief from medical
therapy. The surgery consists of introducing
probes via frontal burr holes for ablation of the
posteroventral portion of the globus pallidus
interna (Fig. 5.32). The goal of the procedure is
to interrupt excessive inhibitory output from the
basal ganglia. On CT, the pallidotomy lesions
appear as hypoattenuating foci of encephaloma-
lacia that become more pronounced over time.
On MRI, acute pallidotomy lesions are usually
hyperintense centrally on T1 and hypointense
centrally on T2 due to hemorrhage surrounded by b
a rim of T2 hyperintensity and hypointensity on
T1 and GRE, which represents edema. Restricted
diffusion due to focal cytotoxic edema can also
be encountered. Eventually, the lesion-edema
complex evolves into a smaller focus of low T1
signal and high T2 signal. Lesion sizes can be
variable depending upon technique implemented.
Fig. 5.32 Pallidotomy. The patient has a history of

Parkinson’s disease and underwent pallidotomy approxi-
mately 1 year prior to imaging on the left side and several
days earlier on the right side. Axial CT image (a) shows
hypoattenuating foci in the bilateral globus pallidi. The
lesion on the right is more recent and slightly less hypoat-
tenuating than the lesion on the left. Axial T2-weighted (b)
and axial T1-weighted (c) images show subacute blood
products within the right pallidotomy lesion surrounded by
edema and fluid within the chronic left pallidotomy lesion
5.3.3 Cingulotomy (Fig. 5.33). There can be T1 hyperintensity due

to petechial hemorrhage, as well as T2 hyperin-
5.3.3.1 Discussion tensity from edema and restricted diffusion due
Cingulotomy is a form of psychosurgery that to ischemia during the early postoperative period,
is used to treat conditions, such as intractable which then evolves over time. Diffusion tensor
obsessive-compulsive disorder. The procedure imaging is also useful for confirming interruption
can be performed in a minimally invasive man- of the cingulum. In particular, the dorsolateral
ner via thermal ablation. This process results in region of the cingulotomy lesion is associated
necrosis of the surrounding brain tissue, which with improved behavior.
appears as concentric rings of signal abnormality
a b
Fig. 5.33 Bilateral anterior cingulotomy. The patient has microelectrode insertion site in the bilateral anterior
a history of medically intractable obsessive-compulsive cingulate gyri. The diffusion-
weighted image (d) and
disorder treated with bilateral stereotactic microelectrode- ADC map (e) show circular zones of restricted diffusion
guided anterior dorsal cingulotomy. Axial T2-weighted consistent with ischemia. The color fractional anisotropy
(a) and coronal (b) and sagittal (c) T1-weighted MR map (f) shows interruption of the bilateral anterior cingu-
images show concentric rings of signal changes at each late fiber tracts
c d
e f
5.3.4 Subcaudate Tractotomy the midline, and 10–11 mm above the planum
and Limbic Leucotomy sphenoidale (Fig. 5.34). Limbic leucotomy is
a combination of cingulotomy and a ventral
5.3.4.1 Discussion lesion similar to that of subcaudate tractotomy
Stereotactic subcaudate tractotomy is performed (Fig. 5.35). Following subcaudate tractotomy
for treating severe cases of obsessive-compulsive and limbic leucotomy, rostral atrophy can be
disorder. The procedure consists of disrupting identified on conventional imaging. In addition,
the fiber tracts between the orbitofrontal cortex diffusion tensor imaging can depict the absence
and the thalamus, which are located approxi- of normal communicating white matter tracts
mately 5 mm anterior to the sella, 15 mm from between the inferior frontal lobes.
a b
Fig. 5.34 Subcaudate tractotomy. The patient has a his- surrounding the microelectrode insertion sites. Diffusion-
tory of medically intractable obsessive-compulsive disor- weighted imaging (c) and corresponding ADC map (d)
der. Axial (a) CT image shows paired hypoattenuating show that these zones have restricted diffusion, consistent
lesions in the bilateral subcaudate nucleus. T2-weighted with acute lesions
images (b) demonstrate concentric T2 hyperintense zones
c d
a b
Fig. 5.35 Limbic leucotomy. Axial FLAIR (a), coronal lesions in the bilateral anterior cingulate gyri (arrow-
T1-weighted (b), sagittal T1-weighted (c), and diffusion heads) and region of the anterior perforated substance
tensor directional color map (d) MR images show chronic (arrows). There is also atrophy of the fornices
5.3.4.2 Thalamotomy changes after thalamotomy correlates with the

Essential tremor can be treated by lesioning of degree of clinical improvement in essential
the ventralis intermedius nucleus of the thalamus. tremor. Skull characteristics, however, can affect
This can be accomplished via transcranial MR the size of the lesions and should be evaluated
imaging-guided focused ultrasound lesion prior to focused ultrasound.
inducement, which is a noninvasive technique
that generates heat at the site where numerous
ultrasound beams intersect, utilizing MRI ther-
mography guidance. Lesions are visible on
T2-weighted images already apparent immedi-
ately after sonication and the lesions enhance-
ment due to blood-brain barrier disruption. Over
the course of a week after sonication, edema
becomes more prominent, enhance, and become
more distinct on T1-weighted images. Beyond 1
month after sonication, the lesions decrease in
size (Fig. 5.36). Thalamotomy has effects on
many other structures, which may be apparent on
DTI. For example, there is decreased fractional
anisotropy in the ipsilateral pre- and postcentral
subcortical white matter in the hand knob area;
the region of the corticospinal tract in the cen-
trum semiovale, in the posterior limb of the inter-
nal capsule, and in the cerebral peduncle; the Fig. 5.36 Thalamotomy by focused ultrasound for
thalamus; the region of the red nucleus; the loca- essential tremor. Postoperative axial T1-weighted MRI
shows a focal defect in the ViM nucleus of the left thala-
tion of the central tegmental tract; and the region mus created by ultrasound (Courtesy of Daniel Cavalcante
of the inferior olive. The magnitude of the DTI and Ryder Gwinn)
5.3.5 Deep Brain Stimulation (DBS) of insulated metallic wires that are connected to
a pulse generator and battery pack that are buried
5.3.5.1 Discussion in the subcutaneous tissues of the scalp, chest, or
DBS is used to treat symptoms of Parkinson’s abdomen, depending on the model and number
disease, essential tremor, Tourette’s, and intracta- of pulse generators required. Although the elec-
ble thalamic pain syndrome, among other condi- trodes are normally secured to the calvarium,
tions. Electrodes can be introduced via burr holes displacement is a potential complication that
into the thalamus, globus pallidus, cerebellum, or can be readily assessed on CT (Fig. 5.39). Other
subthalamic nucleus depending on the underlying complications include electrode fracture, “twid-
condition (Figs. 5.37 and 5.38). Precise position- dler syndrome,” and hemorrhage along the elec-
ing of the electrodes can be achieved by the use trode tract, which is actually more common after
of intraoperative stereotactic guidance and physi- removal (13%) than during insertion (2%), and
ologic localization. The electrodes are comprised ischemic infarction (0.4%) (Fig. 5.40).
a b
Fig. 5.37 Subthalamic nucleus stimulation. The patient has a history of Parkinson’s disease. The skull radiograph (a),
coronal CT (b), and coronal T1-weighted MRI (c) show bilateral DBS electrodes positioned in the subthalamic nuclei
Fig. 5.38 Ventralis caudalis nucleus stimulator. The

patient has had multiple aneurysms clipped and suffers
from a thalamic pain syndrome secondary to hemorrhage
and infarction. Axial CT image shows an electrode posi-
tioned in the right anterior thalamus (arrow). There is
encephalomalacia across the right superior temporal
gyrus, insula, and thalamus
a c
Fig. 5.39 Electrode migration. Initial postoperative axial patient with dystonia. Subsequent axial (c) and coronal
(a) and coronal (b) CT images show satisfactory position- (d) CT images show marked interval retraction of the
ing of bilateral globus pallidus internus electrodes in a right electrode
Fig. 5.40 Brain stimulator insertion-associated infarct.

Axial CT image obtained after recent right deep brain
stimulator implantation shows hypoattenuation and swell-
ing of the right lentiform nuclei (arrowheads), adjacent to
the electrode (arrow)
5.3.6 E
pidural Motor Cortex a
Stimulator
5.3.6.1 Discussion
Epidural motor cortex stimulation has been
used to treat various types of chronic, intracta-
ble neuropathic pain. These devices are
implanted in the epidural space overlying the
motor strip through a craniotomy using an
intraoperative guidance system (Fig. 5.41).
The device is attached via a connecting wire to
a programmable pulse generator that is usually
buried in the infraclavicular fossa subcutane-
ous tissues.
Fig. 5.41 Epidural motor cortex stimulator. The patient

has a history of medically intractable left-sided facial
pain. Frontal (a) axial CT image (b) show four leads posi-
tioned over the surface of the right hand and face motor
strip (arrows)
5.3.7 N
eural Interface System sclerosis. The system essentially converts thought
(BrainGate) into action. The device consists of a minute sub-
cortical silicon electrode array sensor that is
5.3.7.1 Discussion implanted along the motor strip region of the arm
The BrainGate is a neural interface system that is via microcraniotomy and wires run from the
used to decode neural signals in order to control electrode to a post affixed to the surface of the
a computer program or artificial arm in p araplegic skull (Fig. 5.42). The main complications include
patients, such as those with amyotrophic lateral hemorrhage and infection.
a b
Fig. 5.42 BrainGate. The patient has a history of amyo- coronal (c) CT images show the tiny electrode array
trophic lateral sclerosis with quadriplegia and locked-in (arrow) implanted in the arm motor strip region connected
syndrome. Lateral (a) scout image and axial (b) and via wires to the post attached to the skull
5.3.8 Microcatheter Subthalamic 5.3.9 S

eizure Monitoring Electrodes
Infusion of Glutamate and NeuroPace
Decarboxylase
5.3.9.1 Discussion
5.3.8.1 Discussion Subdural electrode grids and arrays provide elec-
Gene transfer of glutamic acid decarboxyl- trographic monitoring to localize seizure foci
ase (GAD) is a promising treatment for medi- for possible resection. These can be implanted
cally intractable Parkinsonism. The vector for as arrays of individual strips (Figs. 5.44 and
GAD is injected into the subthalamic nuclei via 5.45). The electrode grids can cover a large
microcatheters. GAD modulates the produc-
area and require craniotomy for implantation,
tion of GABA in the subthalamic nucleus and while individual strips can be inserted through
improves basal ganglia function. A small quan- burr holes. The duration of monitoring can last
tity, approximately 35 μl, of the vector solution days to weeks. Once the seizure focus is identi-
is infused and is usually not appreciable on imag- fied, the electrodes can be removed at the time
ing. However, the fine microelectrode tracts may of therapeutic epileptogenic tissue resection.
be visible (Fig. 5.43). Alternatively, the electrodes can be removed
noninvasively if bioresorbable components are
utilized.
Depth electrodes are also used to moni-
tor epilepsy in patients with non-lateralizing
scalp EEG and/or discordant imaging stud-
ies. However, in contrast to subdural elec-
trode placement, depth electrodes are inserted
into the brain parenchyma through burr holes
(Fig. 5.46). Consequently, the recorded seizure
discharges are usually better developed in the
depth electrodes. Yet another approach for sei-
zure monitoring is insertion of the electrodes
through the foramen ovale (Fig. 5.47). These
can be particularly useful for lateralization of
temporal lobe activity.
NeuroPace is a device used for both the detec-
Fig. 5.43 Subthalamic infusion of glutamate decarbox- tion and treatment of medically refractory partial
ylase. Coronal post-contrast T1-weighted MRI shows epilepsy. The device components include a
bilateral thin microcatheter tracts (arrows) leading toward
the subthalamic nuclei. The microcatheters were intro- neurostimulator, depth leads, and cortical strip
duced via bifrontal burr holes leads (Fig. 5.48). The neurostimulator is a
programmable, battery-powered, microprocessor- to normalize brain activity before the patient

controlled device that delivers a short train of experiences seizure symptoms.
electrical pulses to the brain through implanted Complications associated with electrode grid
leads. A wand and telemetry interface is used for implantation occur in 3–8% of cases and mainly
communication with the implanted neurostimu- include subdural hematomas (Fig. 5.49) and
lator, allowing the recorded electrocorticogram infection (Fig. 5.50). Epidural hematomas and
to be viewed in real time on a computer using cerebral edema are less common. Imaging plays
specialized software. The neurostimulator can a role in identifying such complications, although
detect abnormal electrical activity in the brain the associated streak artifact from the grids on
and respond by delivering electrical stimulation CT limits a detailed assessment.
a b
Fig. 5.44 Electrode strips. Axial CT image (a) shows the brain in the middle and posterior fossa. CT volume
electrode wires coursing through a temporal burr hole. intensity projection (VIP) image (b) shows the course of
The electrodes are positioned along the surface of the bilateral electrode strips
a b
Fig. 5.45 Electrode grids. CT scout image (a) shows the the left cerebral hemisphere. Photograph of subdural grid
64-channel electrode grid in position. Axial CT image (b) and strip electrodes (c)
shows the metallic subdural electrode grid array overlying
a b
Fig. 5.46 Depth electrodes. Scout (a) and axial CT (b) images demonstrate numerous bilateral depth electrodes
a b
Fig. 5.47 Foramen ovale electrodes. Scout (a) and coronal CT (b) images show bilateral electrode wires (arrows)
coursing through the foramen ovale
a b
Fig. 5.48 NeuroPace. Scout (a) and axial (b) CT images demonstrate both subdural and depth electrodes in position.
The pulse generator is implanted in the subgaleal space
Fig. 5.49 Subdural hemorrhage related to electrode grid

implantation. Axial CT image obtained after recent sur-
gery shows a heterogeneous subdural fluid collection
overlying the left hemisphere electrode grids and midline
shift to the right
a b
Fig. 5.50 Electrode-associated infection. The patient The axial post-contrast T1-weighted MRI (b) shows a
presented with fever and drainage from site of the subdu- ring-enhancing collection in the right frontal lobe (arrow),
ral electrode insertion. Axial CT image (a) shows a gas- as well as regional leptomeningeal and pachymeningeal
containing subdural collection overlying the deep brain enhancement
electrodes. The subdural electrodes were then removed.
5.3.10 Corticectomy
a
5.3.10.1 Discussion
Corticectomy is performed to eliminate seizure
foci and consists of resecting the neocortex in the
region of an epileptogenic focus with sparring of
the underlying white matter. The result can be
appreciated on imaging, in which the bare white
matter is surrounded by cerebrospinal fluid
(Fig. 5.51).
Incomplete excision is the main predictor of
poor surgical outcome, and reoperation may be
appropriate for selected patients with intractable
partial epilepsy who fail to respond to initial sur-
gery. Comparison with the preoperative imaging
b
is helpful, since the residual foci of cortical dys-
plasia can be subtle. Functional MRI and high-
resolution sequences are particularly useful in
planning additional surgery, since the eloquent
areas can be delineated (Fig. 5.52).
Fig. 5.51 Corticectomy. The patient has a history of

tuberous sclerosis and intractable seizures. The patient
underwent surgery in which a portion of the right frontal
cortex was removed and carefully separated from the
underlying white matter. Coronal (a) and 3D (b)
T1-weighted MR images show decorticated white matter
in the right frontal lobe
a b
Fig. 5.52 Residual lesions after corticectomy. The Postoperative fMRI (b) obtained after lesionectomy for
patient is a right-handed white male with a long-standing excision of the epileptogenic focus shows small foci of
history of intractable epilepsy secondary to a cortical dys- residual cortical dysplasia (arrows) adjacent to the surgi-
plasia in the superior frontal region. Preoperative fMRI cal cavity. However, the eloquent zones (colored areas)
(a) shows a left frontal lobe cortical dysplasia (arrow). have been preserved
5.3.11 Selective Epilepsy of entire regions of brain. Depending on the nature

Disconnection Surgery of the seizure focus, this can be accomplished via
and Quadrantectomy minimally invasive thermal ablation procedures for
disrupting very focal white matter tracts (Fig. 5.53)
5.3.11.1 Discussion or quadrantectomy for transecting wider areas of
The propagation of seizures associated with a tissue, such as temporoparietooccipital disconnec-
diffusely abnormal quadrant of the brain can be tion for motor-sparing epilepsy surgery (Fig. 5.54).
impeded by selective disconnection of the under- The disconnection foci or tracts can be readily
lying white matter tracts, as opposed to resection depicted on postoperative MRI, if needed.
a b
Fig. 5.53 Selective frontal lobe disconnection via radio- (encircled) created in the right forceps minor in a patient
frequency ablation. Axial inversion recovery T1-weighted with intractable epilepsy related to Sturge-Weber syn-
(a) and T2-weighted (b) MR images show the lesions drome with a diffusely atrophic anterior right frontal lobe
a b
Fig. 5.54 Quadrantectomy. Axial (a) and sagittal (b) T1-weighted MR images show partial temporoparietooccipital
disconnection, with blood products along the surgical margins (arrows)
5.3.12 Hypothalamic Hamartoma 5.3.13 Callosotomy

Thermal Ablation
5.3.13.1 Discussion
5.3.12.1 Discussion Callosotomy, or surgical division of the corpus
Hypothalamic hamartomas can be difficult to callosum, has been used successfully to treat
reach and remove via open surgical and endo- intractable seizures, particularly drop attacks.
scopic techniques. Thermal ablation offers a min- Division of the corpus callosum can be partial
imally invasive option in cases of associated (Fig. 5.56) or total and can be performed via ther-
epilepsy. Notably, it is not necessary to ablate the mal ablation (Fig. 5.57). MRI is the most suitable
entire lesion, but it may be sufficient to interrupt modality for depicting the extent of the surgical
the fiber tracks exiting the hamartoma. Therefore, lesioning. The most common postoperative find-
one should not be surprised to find that the abla- ings include surrounding T2 hyperintensity
tion zone occupies just a portion of the lesion on related to edema in over 20% of cases within
postoperative imaging (Fig. 5.55). 1 week and corpus callosum hematoma in 15% of
cases. Other changes following callosotomy
include atrophy and signal abnormalities in the
cerebral white matter, perhaps related to Wallerian
degeneration. The microstructural changes in the
transected fibers can persist for many years after
surgery and can be detected on diffusion tensor
imaging, including fractional anisotropy and
apparent diffusion coefficient maps. Therefore,
diffusion tensor imaging is useful for depicting
which fibers of the corpus callosum remain intact.
Fig. 5.55 Hypothalamic hamartoma laser ablation.

Coronal post-contrast T1-weighted MRI shows the
peripherally enhancing ablation zone at the neck of the
large hypothalamic hamartoma. The patient’s seizures
improved after a transient increase in activity shortly after
the procedure
a b
Fig. 5.56 Partial callosotomy. Sagittal T1-weighted (a) imaging tractography map (c) shows interruption of cor-
and axial FLAIR (b) images show a defect in the body of pus callosum body white matter tracts between the genu
the body of the corpus callosum (arrow). Diffusion tensor and splenium of the corpus callosum (arrows)
5.3.14 Anterior Temporal Lobectomy
5.3.14.1 Discussion
Anterior temporal lobectomy is performed for
intractable seizures, particularly those caused by
mesial temporal sclerosis. Varying degrees of
temporal lobe resection can be performed, and a
balance between minimizing the risk of postop-
erative deficits versus maximizing the likelihood
of seizure control is sought. In general, the length
of the resection is up to 4 cm in the dominant
hemisphere and up to 6 cm in the nondominant
hemisphere (Figs. 5.58 and 5.59).
There are certain imaging findings that can be
encountered following temporal lobectomy. For
example, increased enhancement of the choroid
plexus has been reported in over 80% of cases of
Fig. 5.57 Callosotomy via laser ablation. Coronal temporal lobectomies performed for seizure
T2-weighted MRI shows the ablation zone with concen- treatment within the first week of surgery. The
tric areas of different signal characteristics in the right
aspect of the corpus callosum body (arrow). Several other pattern of enhancement is sometimes nodular or
lesions were created along the corpus callosum mass-like and can be mistaken for more serious
pathology (Fig. 5.60). Concomitant enlargement cant mechanism of recurrent epilepsy in patients

of the choroid plexus occurs in the majority of with a seizure-free period after surgery. In addi-
cases, likely secondary to reactive hyperemia. An tion, decreased fractional anisotropy is frequently
enlarged choroid plexus can also herniate into the observed ipsilateral to the surgery (Fig. 5.62).
surgical defect in the floor of the lateral ventricle The decrease is especially pronounced among
temporal horn or atrium. Over time, gliosis forms patients with postoperative visual field deficits.
along the edges of the resection cavity, which Due to the course of the posterior cerebral artery
appears as increased signal and parenchymal vol- adjacent to the medial margin of the anterior tem-
ume loss (Fig. 5.61). Gliosis is commonly poral lobectomy, the vessel is potentially at risk
encountered and does not appear to be a signifi- of injury and consequent infarction (Fig. 5.63).
Fig. 5.59 Nondominant hemisphere anterior temporal

lobectomy. Axial T2-weighted MRI shows a right anterior
Fig. 5.58 Dominant hemisphere anterior temporal lobec-
temporal lobe surgical defect that measures 6.0 cm in the
tomy. Axial T2-weighted MRI shows a left anterior tem-
anteroposterior dimension
poral lobe surgical defect measures 4.0 cm in the
anteroposterior dimension
Fig. 5.60 Choroid plexus changes. Initial postoperative

coronal contrast-enhanced T1-weighted MRI (a) shows
right temporal lobectomy with herniation of the choroid
plexus, which displays mass-like enhancement (arrow).
Coronal contrast-enhanced T1-weighted MRI sequence
obtained 3 months later (b) shows decreased swelling and
enhancement of the choroid plexus changes (arrow)
a b
Fig. 5.61 Postoperative gliosis. The patient has a history the left hippocampus (arrow). Postoperative axial FLAIR
of mesial temporal sclerosis. Preoperative axial FLAIR image (b) shows new high signal and volume loss along
image (a) shows increased signal and decreased size of the left anterior temporal lobectomy margins (encircled)
Fig. 5.62 Optic pathway changes after anterior temporal

lobectomy. The patient has a history of left anterior tem-
poral lobectomy. Fractional anisotropy map shows
decreased anisotropy in the left optic pathway (encircled)
ipsilateral to the temporal lobectomy
a b
Fig. 5.63 Posterior cerebral artery territory infarction. medial occipital lobe (arrow). ADC map (b) shows cor-
Axial FLAIR image (a) shows evidence of recent right responding restricted diffusion (arrow)
anterior temporal lobectomy and high signal in the right
5.3.15 Selective amygdala, anterior hippocampus, parahippo-

Amygdalohippocampectomy campal gyrus, and the subiculum is performed
(Fig. 5.64). However, secondary encephalomala-
5.3.15.1 Discussion cia in the remaining portions of the temporal lobe
Selective amygdalohippocampectomy is a limited is frequently observed due to Wallerian degenera-
form of temporal lobectomy, which can be per- tion. Furthermore, injury to critical adjacent struc-
formed via transcortical, subtemporal, or transsyl- tures, such as the lateral geniculate nucleus with
vian approaches or via laser ablation. Resection associated vision loss, can nevertheless occur
or laser ablation of at least some portions of the with this selective procedure (Fig. 5.65).
a b
Fig. 5.64 Amygdalohippocampectomy. Axial (a) and lobe structures, including the amygdala and hippocampus.
coronal (b) T1-weighted MR images show a small resec- The lateral portions of the temporal lobe are intact
tion cavity (arrows) in the left medial anterior temporal
a b
c
d
Fig. 5.65 Visual pathway injury from laser ablation (encircled). Indeed, there is high FLAIR signal (b) and
amygdalohippocampectomy. The patient presented with restricted diffusion (c) and interruption (d) of a portion of
new coronal T2-weighted MRI (a) shows the site of abla- the left optic radiations and lateral portions of the thala-
tion involving the left hippocampus, as well as the adja- mus (arrows), as well as the pulvinar (arrowheads)
cent temporal stem and lateral portion of the thalamus
5.3.16 Hemispherectomy from the hemisphere are usually termed anatomi-

cal hemispherectomy, classical hemispherec-
5.3.16.1 Discussion tomy, hemidecortication, or hemicorticectomy
Hemispherectomy is mainly reserved for treating (Fig. 5.67).
severe intractable seizure and rarely for glioma- On postoperative imaging, the hemispherec-
tosis cerebri. Several hemispherectomy tech- tomy resection cavity fills with fluid during the
niques can be performed depending on the first few days after surgery. With functional
location and extent of seizure foci, and they can hemispherectomy, the remaining disconnected
be total or partial. Techniques that use partial cor- portions of the cerebral hemisphere eventually
tical removal and hemisphere disconnection are become atrophic. With complete anatomic hemi-
termed functional hemispherectomy or hemispherectomy, duraplasty material is used to seal
spherotomy (Fig. 5.66). On the other hand, tech- the interhemispheric fissure and prevent hernia-
niques that result in complete cortical removal tion of the remaining hemisphere.
a b
Fig. 5.66 Functional hemispherectomy. The patient has (a and b) show residual portions of the right frontal, tem-
a history of Rasmussen’s encephalitis recently treated poral, and occipital lobes, which are partially detached
with partial right hemispherectomy. Axial FLAIR images from the remainder of the brain
a b
Fig. 5.67 Anatomical hemispherectomy. The patient has of the right cerebral hemisphere. Duraplasty material
a history of intractable seizures related to Sturge-Weber (arrow) spans the interhemispheric fissure. 3D time-of-
syndrome treated via complete resection of the right cere- flight MRA (c) demonstrates the absence of the right
bral hemisphere several years prior. Axial CT image (a) MCA in the mid M1 segment status post ligation
and coronal T2-weighted MRI (b) show complete absence
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Imaging of Cerebrospinal Fluid
Shunts, Drains, and Diversion 6
Techniques
and David Frim
6.1 Types of Procedures inserted into the ventricular space via a transcra-
nial approach after creating a burr hole along the
6.1.1 External Ventricular Drainage coronal suture at the mid-pupillary line or sec-
ondarily along the parieto-occipital junction one-
6.1.1.1 Discussion third of the way from the ear to the vertex.
External ventricular drains (EVD) are used for a Imaging may be performed to assess the status of
variety of purposes, including temporary decom- the ventricular system, as well as to evaluate for
pression of an enlarged ventricular system and complications, which include infection, hemor-
acute hydrocephalus from tumor obstruction in rhage, excess drainage, catheter obstruction,
order to better define the resection or following cerebrospinal fluid leak, and malpositioning,
subarachnoid hemorrhage. An EVD catheter is which may require repositioning.

Department of Radiology, University of Chicago
P.-L.A. Westesson, M.D., Ph.D., DDS
Division of Neuroradiology, University of Rochester
Medical Center, Rochester, NY, USA
D. Frim, M.D., Ph.D.
Section of Neurosurgery, University of Chicago

DOI 10.1007/978-3-319-52341-5_6
6.1.2 Ventriculoperitoneal up to 70–80% of patients during their lifetime.

(VP) Shunts Overall, programmable VP shunts have a similar
failure rate as standard shunts. However, the pres-
6.1.2.1 Discussion sure adjustment capability of programmable VP
VP shunting consists of diverting cerebrospinal shunts leads to patient improvement in over 50%
fluid from an intracranial compartment to the of cases. Complications include the following,
peritoneum via a catheter and is commonly perfor which examples are depicted later in this
formed to treat hydrocephalus. VP shunt devices chapter:
consist of a ventricular catheter, valve, and a dis-
tal catheter (Figs. 6.1 and 6.2). The catheter por- • Infection (most common: 5–47%)
tion of a VP shunt is composed of extruded • Obstruction (usually proximal: emergency
Silastic tubing impregnated with a radiopaque condition due to resulting increased ICP)
material, such as barium, in order to confer con- • Subcutaneous cerebrospinal fluid collections
spicuity on radiographic studies. Integrated res- • Catheter disconnection/migration/retraction
ervoirs can also be added to the proximal shunt (anywhere from mouth to anus!)
catheter, which enables percutaneous access and • Incisional hernia
testing of the shunt system. The built-in reser- • Bowel obstruction/volvulus
voirs are usually positioned within the subgaleal • Viscus perforation
space (Fig. 6.3). • Cerebrospinal fluid pseudocysts
Programmable valves contain radiopaque chi- • Conduit for metastatic spread
ral markers that enable the valve opening pres-
sure setting or performance level to be determined Imaging plays an important role in evaluating
radiographically (Figs. 6.4, 6.5, 6.6, and 6.7). patients with VP shunts. Radiographic shunt
Some models have devices that allow these set- series are commonly performed as an initial
tings to be determined without radiographs. screening for suspected shunt failure. However,
Antisiphon devices are also incorporated into these studies are less sensitive than cross-
some models in order to prevent cerebrospinal sectional imaging modalities. Nuclear medicine
fluid overdrainage, when the patient is upright. shunt studies are uncommonly performed but
While programmable shunts are generally MRI can be used to assess for shunt patency.
compatible up to 3T, there is a potential risk for Radiotracer, usually Tc-99m DTPA or In-111
inadvertent change of settings during MRI scan- DTPA, is injected into to the reservoir (Fig. 6.9).
ning. Thus, it is imperative to verify the settings Normally, the radiotracer material spills freely
following MRI. The pressure settings can be throughout the peritoneal cavity. A focal collec-
adjusted noninvasively using a magnetic tool. tion of radiotracer suggests the presence of a
Furthermore, recent innovations have made avail- pseudocyst. Reflux may normally occur into the
able programmable valves that are resistant to ventricles and the reservoir emptying half-time
environmental magnetic influences. of less than 10 min, although this may vary
Gliosis often forms around the ventricular depending on the type of shunt. A similar con-
shunt catheter tract, but generally does not have cept for evaluating shunt patency is the “shunto-
clinical significance. The gliosis typically appears gram,” which involves injection of contrast
as circumferential low attenuation on CT and material into the shunt valve, and tracking the
high signal on T2-weighted MRI measuring up to flow of the contrast via serial radiographs of the
several millimeters in thickness (Fig. 6.8). cranial, chest, and abdominal components of the
Up to one-third of VP shunts fail within 1 year shunt system is obtained over the course of
of placement, and shunt revision is necessary in approximately 15 min.
6 Imaging of Cerebrospinal Fluid Shunts, Drains, and Diversion Techniques 261
a b
Fig. 6.1 External ventricular drain. Coronal CT image (a) shows the catheter within the right lateral ventricle and the
external portion (arrow). Photograph of an external ventricular drain (b) (Courtesy of Marc Moisi)
a b
Fig. 6.2 Shunt series. Selected radiographs (a–c) show abdomen (arrow); and terminates within the peritoneal
the proximal portion of the shunt catheter overlies the lat- cavity (arrow). Radiolucent portions (encircled) of the
eral ventricle (arrow); exits through a burr hole; tunnels shunt should not be mistaken for discontinuities
into the subcutaneous tissues of the head, neck, chest, and
a b
c d
Fig. 6.3 Delta 1.5 valve VP shunt. Lateral skull radio- post-contrast T1-weighted (d) MR sequences show the
graph (a) and 3D CT (b) images demonstrate the reservoir cerebrospinal fluid-filled reservoir (arrows) positioned in
component (arrows) of the VP shunt containing perfor- the subgaleal space
mance level markers. Axial T2-weighted (c) and coronal
Fig. 6.4 Codman Hakim programmable shunt valve.

Lateral radiograph with magnified view (inset) shows
the components of the device (encircled) with pressure
setting markers
a b
Fig. 6.5 Strata valve programmable shunt. Lateral radio- radiograph, but not on the axial CT image (b). The mag-
graph (a) with magnified view (inset) of the VP shunt netic components of the programmable shunt produce
valve (encircled). The pressure setting can be read on the extensive susceptibility artifacts on MRI (c)
P/L 0.5 P/L 1.0 P/L 1.5 P/L 2.0 P/L 2.5
Fig. 6.6 Valve performance level setting chart (Courtesy of Medtronic)
Fig. 6.7 Photograph of ventriculoperitoneal shunt com-

ponents (Courtesy of Patricia Smith and Sarah Paengatelli)
Fig. 6.8 Catheter-associated gliosis. Axial FLAIR MRI

shows circumferential high signal surrounding the shunt
catheter tract (arrow)
Fig. 6.9 Patent shunt catheter depicted on a nuclear med- tracer into the ventricles via a shunt catheter show unim-
icine shunt study. Sequential 99mTc DTPA shunt images peded passage of radiotracer from the ventricular system
obtained over a 30-min period after injection of radio- into the peritoneal cavity
6.1.3 Atypical Ventricular Shunts
6.1.3.1 Discussion
Other parts of the body can be used as terminals
for the distal portions of ventricular shunt cathe-
ters. Ventriculoatrial, ventriculopleural, ventricu-
lovesical, and ventriculo-gallbladder shunts are
plausible alternatives for diverting cerebrospinal
fluid away from the ventricles in patients with
hydrocephalus, particularly when ventriculoperi-
toneal shunts fail.
• Ventriculoatrial Shunts (Fig. 6.10): The distal

tip of a ventriculoatrial shunt should terminate
in the right atrium or even in the superior vena
cava. Complications particular to
ventriculoatrial shunts include pulmonary

embolism and endocarditis.
• Ventriculopleural Shunts (Fig. 6.11): The ter-
minus is within the pleural space. Variable
amounts of cerebrospinal fluid may accumu- Fig. 6.10 Ventriculoatrial shunt. Frontal radiograph
late in the pleural space, in which up to 20% shows a ventricular shunt tip (arrow) at the level of the
are symptomatic. This complication is more atriocaval junction (arrow)
Fig. 6.11 Ventriculopleural shunt. Frontal radiograph (a) and axial CT (b) show a shunt catheter with distal end
(arrows) located within the left pleural space, where there is cerebrospinal fluid
prevalent in infants due to the smaller surface 6.1.4 Ventriculosubgaleal Shunts

area for fluid resorption.
• Ventriculoureteral Shunts: The terminus of the 6.1.4.1 Discussion
shunt is located in the ureter through a Roux- Ventriculosubgaleal shunting is diversion of intra-
en-Y anastomosis. Diversion of cerebrospinal ventricular cerebrospinal fluid into the subgaleal
fluid can result in electrolyte abnormalities space for temporary absorption by the subcutaneous
and cystitis. tissues of the scalp. These shunts are a relatively
• Ventriculocholecystic Shunts: Shunt tip termi- straightforward, effective, and safe option for tem-
nations in the gallbladder have a satisfactory porary treatment of hydrocephalus.
long-term success rate of over 60%. The most Ventriculosubgaleal shunting can avoid the need for
common complications include obstruction external drainage or frequent cerebrospinal fluid
and cholecystitis, with an incidence of about aspiration in unstable neonates until the cerebrospi-
10% each. nal fluid characteristics and abdomen are suitable
for ventriculoperitoneal shunting. On CT and MRI,
the ventriculosubgaleal shunt catheter can be traced
from the ventricular system to the subgaleal space,
where there is often a variable amount of cerebro-
spinal fluid accumulation (Fig. 6.12).
Fig. 6.12 Ventriculosubgaleal shunt. Sagittal T2-weighted

MRI in a neonate show a pocket of subgaleal cerebrospinal
fluid surrounding the ventriculosubgaleal shunt reservoir
(Courtesy of Tina Young Poussaint MD)
6.1.5 Ventriculo-cisternal lateral ventricle to the cisterna magna at the level

(Torkildsen) Shunts of the foramen magnum (Fig. 6.13). These shunts
are introduced into the lateral ventricle via a pari-
6.1.5.1 Discussion eto-occipital burr hole and then exit to the extra-
The Torkildsen shunt was initially conceived to cranial space via that burr hole to course into the
bypass aqueductal stenosis and allow cerebrospi- foramen magnum where the shunting tube is intro-
nal fluid to drain directly through an extracranial duced into the cervical subarachnoid space.
pathway from the lateral ventricle to the cervical Occasionally, a C1 laminectomy is required for
subarachnoid space. While this technique has been this procedure. The proximity of the distal end of
replaced by endoscopic third ventriculocisternos- the shunt to the cervicomedullary junction can
tomy, the Torkildsen shunt approach is occasion- predispose to upper spinal cord compression,
ally necessary in cases of complex hydrocephalus. rarely resulting in cervical myelopathy. Imaging
The Torkildsen shunt typically courses from a can be used to evaluate such symptoms.
a b
Fig. 6.13 Ventriculo-cisternal shunt. The patient has a from the right lateral ventricle, inferiorly behind the cere-
history of chronic headaches and multiple shunts, includ- bral hemisphere and cerebellum, and terminating at the
ing a Torkildsen shunt that was placed many years before. level of the foramen magnum. There is a right occipital
Lateral radiograph (a) and axial CT images (b–d) demon- burr hole, through which the catheter was introduced
strate the course of the internal shunt catheter (arrows)
6.1.6 Percutaneously Accessed for decompression and connected to the reservoirs

Cerebrospinal Fluid (Fig. 6.14). The reservoir can be accessed percuta-
Reservoirs neously using a needle. Ventricular reservoirs can
also be converted into ventriculosubgaleal shunts
6.1.6.1 Discussion or ventriculoperitoneal shunts, as many of these
The subcutaneous cerebrospinal fluid devices con- also have side ports. Complications of ventricular
sist of reservoirs positioned over the calvarium in reservoirs include skin erosion and intracranial
the subgaleal space and catheters inserted into the migration, which may require endoscopic retrieval,
intracranial compartment. The catheters can be as well as generic complications encountered with
inserted into the ventricular system or tumor cyst all shunting systems.
a b
Fig. 6.14 Percutaneous cerebrospinal fluid reservoir with catheter in ventricular system. Scout images in two different
patients (a, b) show the reservoirs (encircled) in the scalp connected to ventricular catheters
6.1.7 Subdural-Peritoneal Shunts collection can flow into the peritoneal space
(Fig. 6.15). Compared with burr hole decompres-
6.1.7.1 Discussion sion and drainage alone, subdural-peritoneal
Subdural-peritoneal shunting devices can be used shunts result in a lower recurrence rate.
to treat chronic subdural hematomas that are suf- Complications include acute subdural hematoma,
ficiently degraded to a fluid state, such that the subdural empyema, and cerebral edema.
a b
Fig. 6.15 Subdural-peritoneal shunt for chronic hema- taneous tissues and runs toward the abdomen. The corre-
toma. Lateral radiograph (a) shows that the catheter tip sponding coronal CT image (b) shows the catheter tip
lies just beneath the calvarium, in the subdural space (arrow) located within the right frontal convexity fluid
(arrow). The rest of the catheter is tunneled in the subcu- collection
6.1.8 Cystoperitoneal decompression of arachnoid cysts into the perito-

and Cystoventriculostomy neal cavity (Fig. 6.16). Meningoceles and cystic
Shunts schwannomas are also sometimes amenable to
cystoperitoneal shunting. Internal drainage of
6.1.8.1 Discussion arachnoid cysts into regional ventricles or cis-
In rare instances, arachnoid cysts can cause terns via stereotactic cystoventriculostomy is
symptoms and require surgical intervention. In another feasible treatment approach, in which a
some reports, cystoperitoneal (subarachnoid- drain is inserted in the cyst lumen and directed
peritoneal) shunting has proven effective for into an adjacent ventricle or cistern (Fig. 6.17).
a b
Fig. 6.16 Cystoperitoneal shunting. The patient has a over the left hemisphere, not in the expected location of
history of ventriculoperitoneal shunt placement for arach- the ventricular system. Axial CT image (b) shows a cysto-
noid cyst and presents with headache. Frontal radiograph peritoneal shunt catheter (arrow) within a large left fron-
(a) shows that the tip of the shunt catheter (arrow) projects totemporal convexity arachnoid cyst
a b
Fig. 6.17 Cystocisternal shunt. The patient has a history which exerts mass effect upon the spinal cord and medulla
of arachnoid cyst secondary to Candida meningitis with (*). Postoperative axial (b) T2-weighted MRI demon-
obstruction of cerebrospinal fluid at the level of craniocer- strates a drainage catheter (arrow) within the subarach-
vical junction, resulting in cord compression. Preoperative noid space anterior to the cervicomedullary junction
sagittal T2-weighted image (a) shows a cerebrospinal
fluid intensity collection at the craniocervical junction,
6.1.9 Syringosubarachnoid fluid pathways via myelotomy and insertion of a

and Syringopleural Shunts Silastic T-shaped tube. The tube extends from the
syringohydromyelia cavity to the subarachnoid
6.1.9.1 Discussion space, into which the excess cerebrospinal fluid
Direct intervention for syringohydromyelia is drains (Fig. 6.18). The T-shaped configuration of
generally considered a rescue procedure and can the tube allows cerebrospinal fluid to drain from
be accomplished via syringosubarachnoid or both superior and inferior directions in the
syringopleural shunting. Syringosubarachnoid syrinx.
shunting can be used to treat syringohydromyelia Syringopleural shunts can also be used to treat
related to a variety of causes, such as tumor, syringomyelia by extending a catheter from the
trauma, and Chiari malformations. This proce- syrinx to the pleural cavity as a negative pressure
dure serves to free the obstructed cerebrospinal terminus (Fig. 6.19).
a b
Fig. 6.18 Syringosubarachnoid shunt. Two patients’ sta- shows a large syrinx (*) in the cervical spinal cord, which
tus post T-tube insertion for cervical spine syringomyelia was successfully decompressed following T-tube inser-
decompression. Sagittal (a) CT image in one patient tion (arrow), as shown on the postoperative T2-weighted
shows the hyperattenuating portions of the T-tube. Sagittal MRI (c). There is also new kyphotic deformity after mul-
preoperative T2-weighted MRI (b) in another patient tilevel laminectomy
Fig. 6.19 Syringopleural shunt. Axial CT image shows a

shunt catheter that extends from the spinal canal along the
left back subcutaneous tissues into the pleural cavity
(arrows)
6.1.10 Lumboperitoneal Shunts through the abdominal subcutaneous tissues and

into the peritoneal cavity (Fig. 6.20). Lumbo
6.1.10.1 Discussion peritoneal shunt catheters can incorporate percuta-
Lumboperitoneal shunting is an alternative method neous programmable or gravity-actuated antisiphon
for treating pseudotumor cerebri and communicat- components, in order to regulate pressure and
ing hydrocephalus separate from ventriculoperito- reduce the risk of overdrainage (Figs. 6.21 and
neal shunting. The procedure consists of introducing 6.22). Reported complications include malfunction,
an intrathecal catheter and tunneling a distal catheter malposition, hemorrhage, and infection.
Fig. 6.22 Lumboperitoneal shunt catheter with gravity-

actuated horizontal-vertical (HV) valve system. Frontal
radiograph shows the lumboperitoneal shunt catheter in
Fig. 6.20 Lumboperitoneal shunt. The patient has a his-
position with gravity-actuated valve component (encir-
tory of pseudotumor cerebri and cerebrospinal fluid rhi-
cled), which is magnified in the inset
norrhea. Axial CT image shows the shunt catheter
(arrows) extending from the spinal canal, through the sub-
cutaneous tunnel, and into the peritoneum
Fig. 6.21 Lumboperitoneal shunt catheter with percuta-

neously programmable valve. Frontal radiograph shows
the lumboperitoneal shunt catheter in position with a pro-
grammable valve component (encircled), which is magni-
fied in the inset
6.1.11 Third Ventriculocisternostomy The hemodynamic changes induced by third

ventriculocisternostomy can be detected on
6.1.11.1 Discussion MRI (Fig. 6.23). In particular, the sagittal phase-
Endoscopic fenestration of the anterior floor of contrast cine sequence is the gold standard for
the third ventricle (Liliequist’s membrane) cre- evaluating cerebrospinal fluid flow dynamics.
ates an alternative route for cerebrospinal fluid Following successful third ventriculostomy, a
into the subarachnoid space via the prepontine flame-shaped jet of high signal (flow) intensity
cistern. This procedure bypasses obstruction at across the floor of the third ventricle is charac-
the level of the Sylvian aqueduct and restores teristic. A jet of cerebrospinal fluid can also
cerebrospinal fluid flow out of the ventricular manifest on T2-weighted sequences. With high-
system. Third ventriculocisternostomy is a resolution heavily T2-weighted cisternogram-
minimally invasive alternative to shunt implan- type sequences, the normal Liliequist’s
tation and is indicated for patients with aque- membrane can be identified. Following third

ductal stenosis, obstructive tumors, and ventriculostomy, the membrane will appear
obstructive cysts. disrupted.
a b
Fig. 6.23 Third ventriculocisternostomy. Preoperative decrease in size of the third and lateral ventricles. The
sagittal FIESTA (a) shows enlargement of the third and postoperative sagittal phase-contrast MRI (c) shows the a
lateral ventricles. Postoperative sagittal FIESTA (b) strong jet of cerebrospinal fluid (arrow) across the third
shows a defect in Liliequist’s membrane (encircled) and ventriculostomy
6.1.12 Endoscopic Septum and left lateral ventricles. Postoperative MRI can
Pellucidum show the disrupted membranes of the septum pel-
and Intraventricular Cyst lucidum and decrease in size of the cyst after suc-
Fenestration cessful fenestration (Fig. 6.24). Arachnoid and
porencephalic cysts can be successfully fenes-
6.1.12.1 Discussion trated to create a communication with the ven-
Endoscopic fenestration can be performed to tricular system or cisterns, averting the need for a
treat symptomatic septum pellucidum cysts. The shunt catheter. Rarely, tumor cysts are decom-
procedure consists of creating a burr hole, intro- pressed into the ventricular system as a last resort
ducing a cannula and endoscope into the lateral (Fig. 6.25). This approach is generally avoided
ventricles, and coagulating the septum pellu- due to the risk of subsequent hydrocephalus sec-
cidum to allow communication between the right ondary to malabsorption from the cyst contents.
a b
Fig. 6.24 Endoscopic septum pellucidum cyst fenestra- MRI (b) shows bilateral defects in the septum pellucidum
tion. Preoperative T2-weighted MRI (a) shows a dilated (arrows) resulting in decompression of the cyst
cavum septum pellucidum cyst. Postoperative T2-weighted
a 6.1.13 Aqueductoplasty
6.1.13.1 Discussion
Aqueductoplasty with or without stenting is a
treatment option for isolated fourth ventricle
resulting from membranous aqueductal stenosis.
Balloon dilatation can be performed to expand
the obstructed aqueduct of Sylvius (Fig. 6.26).
Alternatively, a small-caliber flexible endoscope
can be used to create a perforation in the offend-
ing membrane and to introduce a stent. Following
aqueductoplasty, the third and lateral ventricles
usually decrease in size. If inserted, the aqueduc-
tal stent is visible as a radioattenuating tubular
structure on CT that extends from the fourth ven-
tricle to the floor of the third ventricle and should
not be misconstrued as a migrated shunt frag-
ment in the appropriate setting.
Fig. 6.25 Endoscopic cyst fenestration into the ventricu- Fig. 6.26 Aqueductoplasty and stenting. Axial CT image
lar system. Preoperative axial T2-weighted MRI (a) shows a stent within the aqueduct of Sylvius (arrow)
shows a large cystic lesion that compresses the left frontal
lobe and abuts the left lateral ventricle. Postoperative axial
T2-weighted MRI (b) shows interval decrease in size of
the cystic lesion, which now communicates with the left
lateral ventricle through a surgical defect
6.1.14 Endoscopic Choroid Plexus indicating decreased cerebrospinal fluid pres-

Cauterization sure. Nevertheless, choroid plexus cauteriza-
tion is often performed in conjunction with
6.1.14.1 Discussion ventriculocisternostomy.
Choroid plexus surgery is an option for treat- Choroid plexus papillomas can cause hydro-
ing hydrocephalus in patients with suspected cephalus due to overproduction of cerebrospinal
cerebrospinal fluid overproduction and patients fluid with rates of over 1.0 mL/min as well as
lacking a septum pellucidum. Choroid plexus subarachnoid obstruction. Total surgical resec-
cauterization can be performed endoscopically tion of the tumor and vascular pedicle is the treat-
and consists of coagulating a portion of the ment of choice. Coagulation of the tumor can
choroid plexus. On imaging, truncation of the facilitate resection. After resection, the hydro-
treated choroid plexus can be appreciated cephalus usually resolves (Fig. 6.28). Additional
(Fig. 6.27). Interestingly, following choroid treatment for hydrocephalus after resection may
plexus cauterization alone, ventricular size be required due to intraventricular hemorrhage,
does not necessarily decrease significantly, inflammation from surgery, and mechanical dis-
although sulci become more prominent tortion of the ventricular system.
a b
Fig. 6.27 Choroid plexus cauterization. Preoperative the left lateral ventricle choroid plexus secondary to ful-
axial T2-weighted MRI (a) shows dilatation of the lateral guration (encircled). Sequelae of left ventricular fenestra-
ventricles, particularly the atrium of the left lateral ven- tion are also demonstrated, with resultant decompression
tricle, resulting in cranial vault deformity. Postoperative of the ventricular system and development of extra-axial
axial T2-weighted MRI (b) shows interval truncation of cerebrospinal fluid
a b
Fig. 6.28 Choroid plexus tumor resection. Preoperative enlargement of the ventricular system. Postoperative post-
axial post-contrast T1-weighted MRI (a) shows a lobu- contrast T1-weighted MRI (b) shows interval resection of
lated mass within the right lateral ventricle and marked the tumor and markedly decreased ventricular size
6.2 Complications Related as enlargement and hypoattenuation on CT

to Cerebrospinal Fluid images corresponding to increased T2 and
Diversion Surgeries decreased T1 signal on MRI that are often ori-
ented transversely with a striated pattern, mainly
6.2.1 C
orpus Callosum Changes within the body of the corpus callosum
Secondary to Shunt (Fig. 6.29). The etiology for the signal changes is
Catheterization likely attributable to compression of the corpus
callosum against the rigid falx cerebri from
6.2.1.1 Discussion hydrocephalus prior to shunting. These changes
Due to its proximity to lateral ventricle shunt tra- are typically not associated with symptoms and
jectories, the corpus callosum is prone to injury should not be misinterpreted as neoplasm, white
during catheter insertion. This can result in linear matter disease, or leukoencephalopathy in par-
areas of high T2 signal in the corpus callosum ticular, the corpus callosum can acquire a scal-
adjacent to the catheter. Corpus callosal swelling loping deformity, which is best appreciated on
can also occur after ventricular shunting for long- sagittal images. Furthermore, the changes often
standing obstructive hydrocephalus. This appears resolve over time.
a b
Fig. 6.29 Corpus callosal swelling. Axial CT image (a) striated high signal in the corpus callosum. Sagittal
shows low attenuation and enlargement of the body of the T1-weighted MRI (c) shows scalloping deformity of the
corpus callosum. Axial T2-weighted MRI (b) shows corpus callosum
6.2.2 Shunt-Associated Intracranial with VP shunting typically runs parallel to the

Hemorrhage length of the tubing and can be circumferential.
Frequently, choroid plexus hemorrhage can lead
6.2.2.1 Discussion to disseminated intraventricular hemorrhage and
Intraparenchymal, subdural, and intraventricular can contribute to shunt malfunction.
hemorrhage associated with placement of VP The development of chronic calcified subdu-
shunts is an uncommon complication, with an ral hematomas is a potential long-term compli-
estimated incidence of 0.3–4% (Fig. 6.30). cation of ventriculoperitoneal shunting. The
Intracranial hemorrhage may present soon after calcifications tend to occur at the margins of the
ventricular catheterization or it can be delayed. fluid collection (Fig. 6.31), but may sometimes
Predisposing factors include underlying paren- be more confluent. When bilateral, these have
chymal friability, venous occlusion, coagulopa- been termed “armored brain.” Although the cal-
thy, multiple catheter passes, choroid plexus cified subdural hematomas can produce symp-
injury, and malpositioning near a vascular struc- toms, they generally do not require further
ture. Intraparenchymal hemorrhage associated intervention.
a b
Fig. 6.30 Shunt-associated hemorrhage. Axial CT image choroid plexus and the posterior horn of the right lateral
(a) obtained 2 days following VP shunt placement shows ventricle (encircled). Axial CT image in a different patient
a focus of right frontal lobe hemorrhage adjacent to the (b) shows subdural hematomas (arrows) that formed
catheter (arrow). There is also hemorrhage within the shortly after shunt catheter insertion.
6.2.3 Intraventricular Fat Migration
6.2.3.1 Discussion
Fragments of subcutaneous adipose tissue can
uncommonly migrate into the intracranial cis-
terns and ventricular system either during place-
ment of a cerebrospinal fluid shunt catheter, since
the catheter is tunneled through subcutaneous fat.
This complication is apparent on MRI and CT as
nodules with fat characteristics within the ven-
tricles or cisterns (Fig. 6.32) can be adherent to
the ventricular walls. Nevertheless, patients are
often not symptomatic from this.
Fig. 6.31 Chronic calcified subdural hematoma. Coronal

CT image shows peripherally calcified bilateral cerebral
convexity subdural collections in a patient with long-
standing ventricular shunting
Fig. 6.32 Intraventricular fat. The patient underwent

recent lumboperitoneal shunt insertion. Coronal CT
image shows fat-attenuation material within the suprasel-
lar cistern and right Sylvian fissure (arrows)
6.2.4 MRI-Induced Programmable checked and reset after the scan (Fig. 6.33). The
Valve Setting Alteration accumulation of cerebrospinal fluid can lead to
ventricular enlargement, unless there is extensive
6.2.4.1 Discussion preexisting ventricular scarring that limits ven-
Recurrent hydrocephalus in patients with tricular expansion. Enlargement of the temporal
indwelling ventricular shunts is a sign of shunt horns is among the earliest findings of this com-
failure. Of note, high-field-strength MRI can plication. Other signs include effacement of the
alter the pressure setting of most percutaneous sulci and transependymal flow of cerebrospinal
programmable cerebrospinal fluid shunts and fluid. Hydrocephalus can result in sutural diasta-
may also result in acute hydrocephalus, mimick- sis and enlargement of cranial diameter in
ing shunt malfunction, if the setting is not children.
a b
d
c
Fig. 6.33 MRI-induced programmable valve setting the Medtronic Strata valve. This change was presumably
alteration. The patient with a percutaneously programma- secondary to the magnetic field. Axial T2-weighted MRI
ble cerebrospinal fluid shunt, presented acutely obtunded (a) shows no ventricular dilatation. Shunt survey (b)
after undergoing MRI at 1.5T the previous day. The pres- obtained before the MRI shows a pressure setting of 0.5.
sure settings were not checked following MRI. The fol- Axial CT image (c) obtained the day after the MRI shows
lowing day, the patient was minimally responsive and was acute massive hydrocephalus and the subsequent shunt
noted that the pressure setting changed from 0.5 to 2.5 on survey (d) shows a pressure setting of 2.5
6.2.5 Ventricular Loculations it can exert mass effect upon surrounding struc-
and Isolated Ventricles tures. On imaging, disparate sizes of the ventri-
cles are apparent, and contrast does not enter
6.2.5.1 Discussion the trapped ventricle on CT ventriculography if
The formation of loculations of cerebrospinal the contrast is injected into the other portions
fluid within the ventricular system can lead to of the ventricular system (Fig. 6.35). The level of
shunt failure. The compartmentalized collection obstruction is often at the foramen of Monro, but
of cerebrospinal fluid can lead to symptoms of can occur anywhere in the ventricular system.
hydrocephalus and may be caused by adhesions Treatment may consist of ventricular catheter
from prior hemorrhage or infection, for example. repositioning, septostomy, foramen of Monro
CT ventriculography performed by injecting con- reconstruction, or implantation of a catheter into
trast into the shunt catheter can be used to delin- the affected ventricle. Isolated ventricles that are
eate the presence of loculations by the lack of not enlarging can be difficult to differentiate from
communication of the contrast material with the asymmetric ventricles, which may also be
rest of the ventricular system (Fig. 6.34). encountered after shunting and do not require
Similarly, an isolated or trapped ventricle is an treatment. Midline shift and progressive increase
uncommon phenomenon that can occur in the in size of the ventricle suggest trapping over sim-
setting of ventricular shunting with adhesion for- ple asymmetry of the ventricles. If there is any
mation and represents a form of focal hydroceph- doubt, short interval imaging follow-up can be
alus. The significance of this complication is that performed.
Fig. 6.35 Isolated fourth ventricle. Sagittal CT ventricu-

logram shows the injected contrast confined to the third
and lateral ventricles and a markedly expanded fourth
ventricle
Fig. 6.34 Ventricular loculation. Axial CT ventriculo-

gram shows the injected contrast confined to a cystic com-
partment (arrow)
6.2.6 Slit Ventricle Syndrome 6.2.7 Chronic Overshunting

and Associated Findings
6.2.6.1 Discussion
Slit ventricle syndrome can be defined as a hydro- 6.2.7.1 Discussion
cephalus patient that presents with headache and Chronically shunted patients occasionally can
narrow ventricles on imaging, with a functioning develop intracranial hypotension secondary to
cerebrospinal fluid shunting device, but an ele- long-term overdraining of cerebrospinal fluid
vated cerebrospinal fluid pressure when tested by that manifests as diffuse meningeal thickening
lumbar puncture. This relatively rare condition and enhancement (Fig. 6.37). This process may
may result from reduced brain compliance, often extend into the cervical spine and rarely results in
due to the use of a siphoning-valve shunting cervical myelopathy. Otherwise, headache is a
device at an early age. On imaging, the ventricles common symptom. However, elderly patients are
appear to be very small and do not increase in usually asymptomatic due to brain atrophy.
proportion to the increased intraventricular pres- Chronic low-pressure ventricular shunting in
sure (Fig. 6.36). The condition can be very seri- children may also lead to hyperostosis cranii ex
ous and should not be misinterpreted as small vacuo. This process is usually diffuse and
ventricles simply due to overshunting. involves predominantly the inner table of both
the skull base and calvarium (Fig. 6.38). On CT,
the new bone formation can display a layered
appearance. In infants, there may be associated
premature closure of the sutures (Fig.6.39),
which in turn can result in a cranial stenosis syn-
drome of elevated intracranial pressure.
Fig. 6.36 Slit ventricle syndrome. The patient had clini-

cal evidence of intracranial hypertension. Coronal CT
image shows small size of the ventricular system with
right transparietal shunt catheter in position
Fig. 6.37 Intracranial hypotension. There is diffuse

thickening and avid enhancement of the meninges. A right
parietal ventriculostomy catheter (arrow) is present
Fig. 6.38 Calvarial hyperostosis. Axial CT image shows

diffuse calvarial thickening in a patient with long-standing
ventricular shunting
a b
Fig. 6.39 Post-shunt craniosynostosis. Axial CT image (b) obtained several months later shows interval closure
(a) after recent ventriculoperitoneal shunt insertion shows of the cranial sutures
patent cranial sutures. Follow-up axial CT image
6.2.8 Shunt-Associated Infections readily demonstrated on CT (Figs. 6.40 and

6.41). Intra-abdominal and subcutaneous
6.2.8.1 Discussion abscess related to the ventricular catheter
Shunt-associated infections may be classified appear as rim-enhancing fluid collections with
as proximal or distal, and it is important to surrounding fat stranding on CT. The most
image both ends of the shunt system in sus- common causative organisms are
pected cases of infection. Proximal ventricular Staphylococcus aureus and epidermidis. On
shunt-associated infections mainly include ven- imaging, ventriculitis can manifest as periven-
triculitis (ependymitis) and meningitis. tricular enhancement and restricted diffusion
Cerebritis and abscess are less common com- associated with intraventricular layering debris
plications. Overall, the incidence of VP shunt- (Fig. 6.42). Treatment generally consists of
associated infection ranges from 2% to 40% per removal of the entire shunt device, an interim
shunting procedure. Distal shunt-associated period of external ventricular drainage and anti-
infections include cellulitis and subcutaneous biotic therapy, and eventual replacement of the
and intra-abdominal abscesses, which can be shunting device at a different site.
a b
d
c
Fig. 6.40 Ventriculitis. Axial FLAIR (a), DWI (b), and (d) show diffuse enhancement along the walls of the bilat-
ADC map (c) show layering debris with restricted eral lateral ventricles. There are also bilateral cererbral
diffusion in the occipital horns of the bilateral lateral convexity subdural fluid collections, left larger than right
ventricles. Axial T1-weighted post-contrast axial MRI

a a
b
b
Fig. 6.41 Cellulitis and subcutaneous abscesses. Axial Fig. 6.42 Intraperitoneal abscess. Axial contrast-
CT image (a) shows extensive skin thickening and subcu- enhanced CT image of the pelvis (a) shows an abscess
taneous stranding along the path of the lumboperitoneal in the midpelvis (arrow). Axial CT of the abdomen
shunt. Subsequent axial CT image obtained after removal (b) shows externalization of the distal end of the ventricu-
of the device (b) shows development of multiple rim- loperitoneal shunt. The tip of the catheter exits the skin of
enhancing fluid collections along the prior shunt tract. the right lower quadrant (arrow)
Staphylococcus aureus was cultured from the wounds
6.2.9 Shunt Malposition Distal shunt catheter migration has been

and Migration reported to occur in many different locations,
including into the scrotum, vagina, heart, lungs/
6.2.9.1 Discussion pleura, rectum, and abdominal wall, among oth-
Proper positioning of shunt catheters within the ers. Retraction into the abdominal wall can lead
ventricles can be challenging particularly in to the formation of a pseudocyst within the sub-
patients with small ventricles. It has been reported cutaneous tissues (Fig. 6.44). Migration of the
that suboptimal ventriculoperitoneal shunt posi- distal shunt into the rectum must be preceded by
tioning occurs in about 25% of cases and that in bowel perforation. Bowel and liver perforation
about 8% of cases, the catheter tip is located by VP shunt catheters are rare occurrences
entirely outside the ventricular system, either too (Fig. 6.45). Imaging is useful to localize the
far proximal or distal. Catheter malposition can migrated shunt device components and associ-
compromise cerebrospinal fluid drainage and ated complications. Management may include
lead to injury of brain parenchyma and associated laparotomy with catheter removal and replace-
symptomatology (Fig. 6.43). ment into another absorptive site.
Fig. 6.43 Shunt catheter malposition. Axial CT image

shows the tip of the shunt catheter in the left thalamus
(encircled). There is a hematoma in the left temporal lobe
a b
Fig. 6.44 Bowel perforation. Frontal radiograph (a) rectum/anus region (arrow). Axial CT images (b, c) show
shows coiling of a VP shunt catheter in the midabdomen. the catheter within the left colon and rectum (arrows)
The catheter then courses in the pelvis and projects in the (Courtesy of Nina Klionsky, MD)
a b
Fig. 6.45 Catheter liver puncture. The patient presented despite recent ventricular shunt insertion. Axial CT image
with worsening neurological status after attempted ven- of the abdomen (b) shows the distal portion of the catheter
triculoperitoneal shunting at another institution. Axial CT within the liver parenchyma, surrounded by a small
image of the head (a) shows marked verntriculomegaly amount of cerebrospinal fluid (arrow)
6.2.10 Shunt Catheter Mechanical less often mechanical trauma. Radiographs as part
Failure of shunt series are usually adequate for depicting
these complications (Figs. 6.46 and 6.47).
6.2.10.1 Discussion Disconnected or fractured shunts have abnormal
Mechanical failure of cerebrospinal fluid shunt lucent gaps. Comparison with prior shunt series
catheters can be due to kinking or disconnection or can be helpful for discerning subtle defects. It
breakage. While kinking is typically an early com- should be noted that some VP shunts contain radio-
plication, disconnection and breakage of the tubing lucent components that should not be misinter-
tend to be late complications that are usually related preted as discontinuities.
to aging/degradation of the catheter material and
Fig. 6.46 Catheter kink. Frontal radiograph shows a

sharp bend (arrow) in a distal ventriculoperitoneal
shunt catheter
a b
Fig. 6.47 Shunt
fracture. Initial lateral
radiograph (a) shows
intact shunt hardware.
Follow up lateral
radiograph (b) when
the patient presented
with new neurological
symptoms shows
interval fracture and
retraction of the
catheter tubing in the
neck (encircled)
6.2.11 Intraparenchymal and are often preceded by cerebrospinal fluid

Pericatheter Cysts edema around the catheter. On imaging, these
and Interstitial Cerebrospinal cysts appear as ovoid collections with characteris-
Fluid tics of cerebrospinal fluid around the shunt cathe-
ter (Fig. 6.48). Low attenuation on CT and high T2
6.2.11.1 Discussion signal on MRI in the surrounding brain paren-
Intraparenchymal pericatheter cysts are rare com- chyma can also be present. The pericatheter cysts
plications of shunt surgery. These typically result are reversible with shunt revision or may resolve
from increased resistance to outflow or obstruction spontaneously with conservative management.
a b
c
d
Fig. 6.48 Pericatheter cyst and interstitial cerebrospinal catheter. The corresponding axial T2 FLAIR (c) and post-
fluid. Initial axial CT (a) image shows an unremarkable contrast T1-weighted (d) MR images show that the col-
course of the right transfrontal VP shunt catheter. Axial lection follows cerebrospinal fluid signal. Although there
CT (b) obtained 3 weeks later shows interval development is high T2 signal in the surrounding white matter, there is
of a low-attenuation collection surrounding the shunt no associated enhancement to suggest abscess
6.2.12 Peritoneal Pseudocysts Pseudocysts are variable in size and appear-

ance. Small, loculated collections tend to be
6.2.12.1 Discussion infected, while large cysts may be sterile cere-
Intraperitoneal pseudocysts associated with brospinal fluid collections, although infection
shunt catheters are localized, walled-off col- with a pseudocyst should be considered regard-
lections of cerebrospinal fluid within the peri- less of size. Large intraperitoneal pseudocysts
toneal cavity, which is often readily depicted may cause bowel obstruction, ventriculomeg-
on CT or ultrasound (Fig. 6.49). Nuclear medi- aly, and increased intracranial pressure, inde-
cine or other shunt studies confirm a communi- pendent of infectious complications.
cation between the catheter and pseudocyst.
a b
Fig. 6.49 Peritoneal pseudocyst. Axial CT image (a) in a different patient (b) shows an intra-abdominal fluid
shows a large, well-defined fluid collection that contains collection surrounding the shunt catheter (arrow)
the distal portion of the shunt catheter. Ultrasound image
6.2.13 Cerebrospinal Fluid Leak signs of postural cerebrospinal fluid hypotension.

Syndrome On imaging, fluid collections with cerebrospinal
fluid characteristics can be found in the soft
6.2.13.1 Discussion tissues adjacent to the catheter, essentially any-
Cerebrospinal fluid leakage is an uncommon where along the course of the catheter (Fig. 6.50).
complication of cerebrospinal fluid shunting pro- There can be associated catheter disconnection or
cedures. Patients characteristically present with dislodgement.
a b
Fig. 6.50 Shunt device associated cerebrospinal fluid patient (b) shows the distal end of the VP shunt has
leakage. Axial CT image (a) shows a cerebrospinal fluid migrated and coiled within the right anterior abdominal
attenuation collection (arrow) surrounding the reservoir wall subcutaneous tissues, resulting in accumulation of
in the left upper neck. Axial CT image in a different cerebrospinal fluid (arrow)
6.2.14 Tumor Seeding and germinoma, among others. Conversely,

intracranial spread of intra-abdominal tumors
6.2.14.1 Discussion into the intracranial compartment via the shunts
Ventriculoperitoneal shunts can rarely serve as a has been reported. Cross-sectional imaging can
conduit for tumor dissemination. Various intra- be used to localize and characterize the meta-
cranial tumors can metastasize to the abdomen static deposits (Fig. 6.51).
via the shunts, including glioblastoma, PNET,
a b
Fig. 6.51 Tumor seeding. Axial CT image of the brain of the abdomen (b) shows irregular masses within the
(a) shows the shunt catheter tip (arrow) penetrating a cor- right abdomen subcutaneous tissues along the course of
pus callosum glioblastoma. Axial post-contrast CT image the shunt (encircled), consistent with metastatic deposits
6.2.15 Shunt Catheter Calcification 6.2.16 Pulmonary Embolism

from Ventriculoatrial
6.2.15.1 Discussion Shunting
Dystrophic calcifications can form around the
silicone tubing of shunt catheters within the sub- 6.2.16.1 Discussion
cutaneous tissues, particularly those impregnated In rare cases, the presence of a catheter in the
with barium (Fig. 6.52). This phenomenon is deep venous system and right atrium can
likely attributable to a fibrotic reaction to the tube. predispose to thrombus formation along the

Calcifications are most commonly encountered in intracardiac portion of the catheter and lead to
the region of the clavicles. The presence of calci- pulmonary embolism. Patients may present with
fication surrounding shunt catheters may be asso- chest pain and shortness of breath. Pulmonary
ciated with malfunction, pain, and fever. Removal embolism protocol CT is the modality of choice
of the affecting tubing can relieve symptoms for evaluating pulmonary artery filling defects
although the catheter can be difficult to remove (Fig. 6.53).
due to associated fibrosis. The condition is readily
depicted on radiographs or CT in which the calci-
fications are usually coarse, irregular, and scat-
tered along the length of the shunt tubing.
Fig. 6.53 Pulmonary embolism associated with ventricu-

loatrial shunting. The patient presented with shortness of
breath after shunt placement. Axial post-contrast CT
image shows a filling defect in a left pulmonary artery
branch (arrow)
Fig. 6.52 Pericatheter dystrophic calcifications. Frontal

radiograph of the neck shows diffuse dystrophic calcifica-
tions along the left VP shunt tube (arrow). A normal-
appearing right shunt catheter is present on the
contralateral side
6.2.17 Chiari Decompression hydrocephalus, craniocervical instability, arach-

Surgery and Associated noid adhesion formation, inflammatory or granu-
Complications lomatous reaction to implanted materials, and
cerebellar ptosis or cerebellar slump syndrome.
6.2.17.1 Discussion Some of these complications may warrant revi-
The goal of neurosurgical intervention in patients sion surgery, and some are discussed in more
with Chiari type 1 malformation is to reduce detail in the following pages.
symptomatic cerebrospinal fluid pressure gradi- Infarction is a rare complication of Chiari I
ents across the craniocervical junction. malformation decompression, but is more likely
Decompression typically involves suboccipital to occur during complex revision surgeries. The
craniectomy and C1 laminectomy, with or with- posterior inferior cerebellar artery territory is
out duraplasty. Regardless of the particular tech- most often involved, and the extent is typically
nique implemented, decompression should result beyond the areas affected by ischemia induced by
in a widened neo-foramen magnum, with cauterization performed for tonsillar reduction.
improved cerebrospinal fluid flow, which can be DWI and FLAIR MRI sequences are useful for
assessed qualitatively or quantitatively via phase- evaluating perioperative infarcts (Fig. 6.57).
contrast imaging, as well as diminished syringo- Pseudomeningoceles consist of cerebrospinal
myelia (Fig. 6.54). fluid collections that extend into the upper neck
There are several adjunct procedures that can and scalp soft tissues from the site of
be implemented in conjunction with Chiari decompression. This phenomenon occurs even if
decompression, particularly as a second resort, duraplasty is performed, since a completely
including craniocervical decompression without watertight closure is not always possible to
or with duraplasty, fourth ventricular stenting, achieve. The pseudomeningoceles can occasion-
endoscopic third ventriculostomy, tonsillar ally produce enough mass effect to aggravate the
reduction, and syringohydromyelia decompres- syringohydromyelia. Furthermore, the pseudo-
sion. In particular, fourth ventricular stenting can meningoceles can also fluctuate in size over time,
be performed when there is obstruction of the particularly with changes related to intracranial
fourth ventricular outflow in patients with refrac- shunting (Fig. 6.58).
tory syringohydromyelia. Silastic tubes that are Arachnoid adhesions can tether the cerebel-
typically used for this purpose are visible on con- lum to overlying dura and impede cerebrospinal
ventional MRI sequences as low-signal-intensity fluid flow. The adhesions are best depicted on
structures on T1- and T2-weighted sequences high-resolution cisternogram type sequences,
(Fig. 6.55). such as FIESTA, CISS, or DRIVE, and appear as
Tonsillar cauterization or reduction leads to a low-signal-intensity bands that distort the paren-
characteristic finding on early postoperative chyma. These are often located posterior to the
imaging, which is essentially related to ischemia cerebellum or at the craniocervical junction and
at the margins of the resected tissues, along with attach to the overlying dura or dural graft
microhemorrhages (Fig. 6.56). Enhancement (Fig. 6.59).
along the margins of the cauterized tissue can Cerebellar slump syndrome can manifest
also be observed in the perioperative period. Over with aggravated symptoms after decompres-
time, the ischemia evolves to encephalomalacia sion surgery for Chiari I malformation due to
with further shrinkage of the inferior cerebellum further inferior descent of the cerebellum,
and greater flow across the neo-foramen which can compress the upper spinal cord and
magnum. distort the brainstem, as demonstrated on MRI
Complications of Chiari decompression (Fig. 6.60). This complication can be predis-
include hemorrhage, infection, stroke, cerebrospi- posed by a neo-foramen magnum that is too
nal fluid leak with pseudomeningocele formation, large.
a b
Fig. 6.54 Expected findings following Chiari decompres- Postoperative, preoperative sagittal T2-weighted MRI (c)
sion surgery. Preoperative sagittal T2-weighted MRI (a) and phase-contrast flow image (d) show a w idened neo-
and phase-contrast flow image (b) show low-lying cere- foramen magnum with improved cerebrospinal fluid flow
bellar tonsils with impeded cerebrospinal fluid flow across and decrease in the degree of syringohydromyelia
the foramen magnum and extensive syringohydromyelia.
Fig. 6.55 Fourth ventricular stent. Sagittal T2-weighted

MRI shows a stent (arrows) traversing the fourth ventri-
cle. Chiari decompression surgery was also performed
a b
d
c
Fig. 6.56 Tonsillar reduction. Axial DWI (a), ADC map (b), FLAIR (c), and SWI (d) show areas of ischemia at the
margins of the bilateral cerebellar tonsils with a few associated microhemorrhages
a b
c
d
Fig. 6.57 Perioperative stroke. The patient is status post image (a) shows edema in the bilateral medial cerebellar
re-exploration of Chiari decompression, direct midline hemispheres. Axial FLAIR (b), DWI (c), and ADC map
myelotomy for syrinx drainage, exploration/reestablish- (d) show corresponding acute infarction in the bilateral
ment of fourth ventricular outflow by stenting from fourth cerebellar hemispheres
ventricle to the cervical subarachnoid space. Axial CT
a b
Fig. 6.58 Pseudomeningocele. Sagittal T2-weighted (a) and T1-weighted (b) MR images show a cerebrospinal fluid
collection extending from the suboccipital craniectomy into the subcutaneous tissues of the posterior neck (*)
Fig. 6.59 Adhesions. Sagittal FIESTA image shows dis-

tortion of the inferior cerebellum associated with a
hypointense band that extends to the overlying dura
(arrow)
a b
Fig. 6.60 Cerebellar slump syndrome. Sagittal crowding of the posterior fossa contents. The calvarium is
T1-weighted (a) and axial FLAIR (b) MR images show markedly thickened, presumably due to chronic shunting
distortion of the brainstem and inferior positioning and effects and decreased intracranial pressure
suspected ventriculoperitoneal shunt failure in pediat-

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Imaging of the Postoperative Skull
Base and Cerebellopontine Angle 7
Daniel Thomas Ginat, Peleg M. Horowitz,
Gul Moonis, and Suresh K. Mukherji
7.1 Anterior Craniofacial using dural patch grafts, which may consist of
Resection pericranial or fascial autograft, acellular cadav-
eric dermal allograft, xenograft (bovine pericar-
7.1.1 Discussion dium), or synthetic collagen-based matrix. The
defect in the floor of the anterior cranial fossa can
Anterior cranial (craniofacial) resection is the be closed with vascularized pericranial or naso-
treatment of choice for aggressive tumors, such septal rotational flaps, titanium mesh, bone graft,
as sinonasal undifferentiated carcinoma (SNUC) synthetic implant, or a combination of these
and esthesioneuroblastoma, that are adjacent to (Figs. 7.1, 7.2, 7.3, and 7.4). In cases of large
or extend into the anterior cranial fossa. This defects, free flap reconstruction may be used.
approach is also sometimes used for resection Vascularized pericranial flaps, which are created
of suprasellar tumors. The procedure consists of by stripping away the periosteum from the outer
extensive removal of the anterior skull base and table of the calvarium, typically demonstrate
nasal cavity and paranasal sinus structures along enhancement on MRI.
with tumor resection. This may require both During anterior cranial resection, the frontal
transnasal and anterior skull base (i.e., transbasal, lobes may be retracted to some degree, which
cranio-orbital) approaches. The dura is repaired predisposes to local ischemia at the site of retrac-
tor placement. Aggressive retraction, which
might be implemented for removal of large
tumors, can avulse the lenticulostriate vessels,
D.T. Ginat, M.D., M.S. (*) leading to basal ganglia infarcts (Fig. 7.5).
Department of Radiology, Infection acquired after anterior cranial resec-
University of Chicago, Chicago, IL, USA tion is predisposed by concurrent partial anterior
e-mail: dtg1@uchicago.eduG
frontal lobectomy, prior craniotomy, persistent
P.M. Horowitz, M.D., Ph.D. cerebrospinal fluid fistula, and high doses of radi-
Department of Surgery,
ation therapy. Alloplastic materials used for
reconstruction and devitalized tissues are also
G. Moonis, M.D.
risk factors for postoperative infection, poten-
New York, NY, USA tially serving as niduses for microorganisms.
S.K. Mukherji, M.D., M.B.A., F.A.C.R.
Wound infections tend to occur along the lateral
Department of Radiology, Michigan State University, forehead where the skin incisions are made
East Lansing, MI, USA (Fig. 7.6), while intracranial infections are often

DOI 10.1007/978-3-319-52341-5_7
in the midline, due to the proximity to the sinona- Another important complication of anterior
sal passages and potential fistula formation cranial fossa resection is encephalocele, particu-
(Fig. 7.7). larly if only a pericranial flap was used to repair
Follow-up imaging is important for monitoring the skull base defect. On CT, a postoperative
tumor recurrence. MRI is the study of choice for encephalocele appears as nonspecific soft tissue
postoperative surveillance (Fig. 7.8). Following attenuation with variable amounts of surrounding
craniofacial resection, MRI often demonstrates cerebrospinal fluid attenuation. Thus, MRI is
enhancing soft tissue related to granulation tis- useful for making the diagnosis since the conti-
sue formation at the resection site in the superior nuity of the lesion with the intracranial brain
nasal cavity that is difficult to differentiate from parenchyma can be readily established and dif-
residual or recurrent tumors, such as esthesio- ferentiated from tumor recurrence or sinus muco-
neuroblastoma. FDG-PET/CT can also be useful sal disease (Fig. 7.11).
for evaluating for the presence of posttreatment Since anterior cranial fossa resection typically
tumor, although infection and inflammation of involves access through the paranasal sinuses in
the resection bed can be hypermetabolic, similar addition to craniotomies, there is the risk of trans-
to recurrent tumor. gressing the lamina papyracea and orbital entry.
Radiation therapy is often administered for This may injure the rectus muscles and other
malignant tumors treated via anterior craniofacial orbital contents (Fig. 7.11). Other complications
resection. This can result in radiation necrosis, associated with FESS can also occur with ante-
which has a characteristic pattern of white matter rior cranial fossa resection. As the normal air flow
signal abnormality and ring-enhancing lesions in through the nasal sinuses is frequently disrupted,
the distribution of radiation field and mainly occurs mucocele formation and chronic inflammatory
6 months to 1 year after treatment (Fig. 7.9). changes in the paranasal sinuses are common.
Fig. 7.1 Illustration of

the anterior cranial fossa
approach with skull base
reconstruction using Pericranial flap and dural patch
pericranial flap and Titanium mesh
dural patch, titanium Bone graft
mesh, and bone graft
7 Imaging of the Postoperative Skull Base and Cerebellopontine Angle 313
a b
Fig. 7.2 Anterior cranial resection with vascularized pericranial flap reconstruction of the anterior cranial fossa
pericranial flap. Sagittal T2-weighted (a), T1-weighted (arrows). The flap appears as a thin sheet that enhances
(b), and post-contrast T1-weighted (c) MR images show
Fig. 7.3 Anterior cranial resection with mesh reconstruc-

tion. Sagittal (b) T1-weighted MRI shows the low-signal-
intensity mesh positioned along the floor of the anterior
cranial fossa (arrow)
a b
Fig. 7.4 Anterior cranial resection with bone graft recon- nasal sinus and skull base resections. There are no residual
struction. The patient has a history of a large sinonasal ethmoid cells. A split calvarial bone graft harvested from
undifferentiated carcinoma (SNUC) involving the ante- the frontal bone was used to close the skull base defect.
rior skull base treated via anterior craniofacial resection. Postoperative coronal post-contrast T1-weighted (d) MRI
Preoperative coronal CT image (a) and coronal post- also shows the extensive anterior craniofacial resection.
contrast T1-weighted (b) MRI show the heterogeneously The low-signal-intensity anterior skull base bone graft lies
enhancing paranasal sinus mass extending through superior to the pericranial flap. There is mucosal thicken-
the cribriform plate and into the anterior skull base. ing, but no evidence of residual or recurrent tumor
Postoperative coronal (c) CT image shows extensive para-
c d
Fig. 7.6 Scalp abscess. Coronal post-contrast T1-

weighted MRI shows a loculated, rim-enhancing col-
lection in the right scalp adjacent to an osteotomy site
(arrow)
Fig. 7.5 Cerebral infarction. Axial diffusion-weighted

image obtained after recent anterior cranial resection
shows restricted diffusion in the right putamen and oper-
cular region of the right frontal lobe, likely secondary to
retraction (arrows)
b Fig. 7.8 Squamous cell carcinoma recurrence after ante-

rior cranial fossa resection. Coronal post-contrast
T1-weighted MRI shows a large heterogeneously enhanc-
ing craniofacial mass that extends across the craniotomy
into the intracranial compartment and right orbit
Fig. 7.7 Intraparenchymal abscess with fistula. The

patient presented with fever after esthesioneuroblas-
toma resection. Axial T2 FLAIR (a) and sagittal (b)
post-contrast T1-weighted MR images show a large left
anterior frontal lobe rim-enhancing cavity containing an
air-fluid level. There is extensive signal abnormality sur-
rounding the abscess, which represents cerebritis
a b
Fig. 7.9 Radiation necrosis. Axial T2 FLAIR (a) and peripherally enhancing lesions, which are in the distribu-
coronal (b) contrast-enhanced T1-weighted MR images tion of the radiation field after anterior cranial resection
show extensive bifrontal edema and heterogeneous
Fig. 7.11 Rectus muscle injury. The patient presented

with right restrictive esotropia following anterior cranial
resection and radiation treatment of a squamous cell car-
cinoma. Coronal post-contrast T1-weighted MR image
shows enhancing, amorphous soft tissue material in the
Fig. 7.10 Encephalocele after anterior cranial resection. right posterior ethmoid air cells that represents scar, which
Coronal T2-weighted MRI demonstrates a large encepha- retracts the medial rectus muscle (arrow) through a defect
locele (arrow) through the anterior cranial fossa defect in the lamina papyracea
7.2 ecompression of Cystic

D p roviding patients with symptomatic relief, such
Craniopharyngiomas as visual recovery. While CT is adequate for con-
firming the positioning of catheters, multipla-
7.2.1 Discussion nar and multisequence MRI is better suited for
delineating the cystic versus solid components,
Resection of craniopharyngiomas often poses a which can evolve considerably following treat-
surgical dilemma since gross total resection is ment and have complex features on follow-up
difficult to achieve with large tumors without exams. Ultimately, the goal of follow-up imag-
injury to surrounding structures. Consequently, ing is to determine if growth has occurred with
residual tumor often remains despite additional associated complications, such as hydrocepha-
radiation and chemotherapy. Nevertheless, the lus, and if there is a dominant cystic component
main gain of surgery is to the associated reduce that could be targeted in a minimally invasive
mass effect. Subtotal decompression can be manner (Fig. 7.14). Postoperative abscess can
accomplished via transsphenoidal or transcra- potentially mimic cyst progression on MRI, but
nial cyst fenestration, with or without perma- the clinical presentation and presence of new
nent catheter implantation (Figs. 7.12 and 7.13), restricted diffusion may help s uggest infection
and can be a suitable alternative to resection for (Fig. 7.15).
a b
Fig. 7.12 Cyst fenestration. Preoperative coronal marked interval decompression of the cystic component.
T2-weighted MRI (a) shows a suprasellar craniopharyn- Although residual tumor is apparent, there is decreased
gioma with a large cyst causing obstructive hydrocepha- mass effect
lus. Postoperative coronal T2-weighted MRI (b) shows
a a
Fig. 7.13 Cyst drainage. Coronal CT image (a) and

coronal T2-weighted MRI (b) demonstrate a drain-
age catheter (arrows) within the cystic portion of the
craniopharyngioma
Fig. 7.14 Postoperative cyst growth. The patient under-

went prior transcranial craniopharyngioma debulking,
with residual enhancing and cystic suprasellar c omponents
(a). While the solid component decreased in size after
radiation therapy, the cystic component increased in size
and caused obstructive hydrocephalus (b), as shown on
the coronal post-contrast T1-weighted MR images
Fig. 7.15 Postoperative infection. Initial coronal

contrast-enhanced T1-weighted MRI (a) obtained after
anterior craniopharyngioma cyst fenestration shows a
residual solid enhancing nodular component of the cranio-
pharyngioma (arrow). Axial post-contrast T1-weighted
MRI (a) and DWI (b) obtained after craniopharyngioma
cyst decompression show leptomeningeal enhancement
and a rim-enhancing fluid collection with restricted diffu-
sion from abscess formation (arrows)
7.3 Transsphenoidal Tumor sal pedicle flaps (Fig. 7.21), and titanium mesh
Resection (Fig. 7.22), each of which has particular imaging
features. Then move it right after the sentence:
7.3.1 Discussion Fat grafts are hyperintense on both T1- and
T2-weighted sequences and decrease in size
The transsphenoidal approach is widely used for over time, such that in most cases, the fat grafts
resecting pituitary tumors (hypophysectomy) and resorb completely after 1 year following surgery
other sellar and parasellar lesions. (Fig. 7.19). Bone remodeling is a chronic pro-
Transsphenoidal surgery consists of accessing cess that sometimes occurs after transsphenoidal
the sella via the nasal cavity and paranasal sinuses resection. This phenomenon manifests as thick-
and typically involves some degree of resecting ening, ossification, and high T1 signal intensity,
the posterior bony septum back to the sphenoid most commonly along the planum sphenoidale
face and performing sphenoidotomy (Fig. 7.16). (Figs 7.16 and 7.19).
The process of drilling through bone during the Nasal stents and sinonasal fluid related to
transsphenoidal approach can leave behind bloody mucus drainage can be encountered on
metallic debris that has detached from the surgi- early postoperative imaging (Fig. 7.23).
cal instruments. These metal particles can be The early postoperative imaging appearance
deposited anywhere along the path of the access of the pituitary after transsphenoidal resection is
route, such as in the nasal cavity and sphenoid variable, ranging from no enhancement to nodu-
sinus. Although it is usually too minute to be lar enhancement to peripheral rim enhancement.
apparent on radiographs, the metal debris can There can also be postoeprative reexpansion of
cause noticeable artifact on MRI (Fig. 7.17). the normal pituitary gland, thickening of the
Giant adenomas or other large lesions of the pituitary stalk, and swelling of the optic appa-
pituitary region are sometimes not amenable to ratus. In addition, there may be a postoperative
resection via transsphenoidal approach alone. mass caused by residual tumor, edema, hemor-
Such tumors require craniotomy and/or a com- rhage, implant material, granulation tissue, or
bined approach that includes transsphenoidal a combination of these. In particular, granula-
and transcranial routes (Fig. 7.18). Less inva- tion tissue can be difficult to differentiate from
sive endoscopic transsphenoidal-transventricular residual tumor on imaging initially. However, on
combined approaches can also be performed in follow-up, granulation tissue typically involutes,
selected cases. while residual tumor is expected to persist or
Fat graft is commonly used to pack skull base grow (Fig. 7.24). In particular, early postopera-
defects after transsphenoidal resection of pitu- tive dynamic MRI after transsphenoidal pituitary
itary region tumors. The packing serves to pre- adenoma resection can be useful for differenti-
vent cerebrospinal fluid leakage, hemorrhage, ating residual tumor from postoperative surgical
and prolapse of intracranial contents into larger changes. Residual tumor from subtotal r esection
defects. Fat grafts are hyperintense on both of pituitary macroadenomas is usually distributed
T1- and T2-weighted sequences and decrease in lateral to the sella, where it is difficult to attain
size over time, such that in most cases, the fat and left behind in order to minimize complica-
grafts resorb completely after 1 year following tions (Fig. 7.25). Indeed, the primary goal of the
surgery (Fig. 7.19). surgery is not necessarily to remove the entire
Other materials used to seal and fill the tumor, but to alleviate the mass effect upon the
sella include gelatin sponge (Fig. 7.20), muco- optic chiasm.
a b
Fig. 7.16 Transsphenoidal approach. Axial (a) and coro- rior wall of the expanded sella, which otherwise has thick-
nal (b) CT images show posterior nasal septostomy and ened walls
sphenoidotomy. There is also a surgical defect in the ante-
a b
Fig. 7.17 Residual metal debris after transsphenoidal T2-weighted MRI in a different patient (b) shows metal
surgery. Sagittal T1-weighted MRI (a) shows metallic susceptibility artifact along the floor of the sella (arrow)
artifact in the posterior nasal cavity (arrow). Coronal
Fig. 7.18 Combined transventricular-transsphenoidal

resection. Coronal T2-weighted MRI shows a linear pas-
sage through the right frontal lobe toward the sellar
region, where there is residual tumor
a b
Fig. 7.19 Fat graft shrinkage and bone remodeling. (arrow). Postoperative sagittal T1-weighted MRI (b)
Initial postoperative sagittal T1-weighted MRI (a) shows obtained 2 years after surgery shows interval fat graft
the T1 hyperintense fat graft within the sella and normal shrinkage and development of high signal intensity in the
intermediate signal intensity of the planum sphenoidale planum sphenoidale (arrow)
Fig. 7.20 Merocel packing. Coronal T2-weighted MRI

shows the packing in the sella and sphenoid sinus, which
appears as a heterogeneous blob (arrow)
a b
Fig. 7.21 Pedicled mucosal flap. Sagittal pre-contrast T1-weighted (a) and post-contrast sagittal T1-weighted (b) MR
images show an enhancing pedicled mucosal flap (arrows) transposed into the sphenoid sinus
b
Fig. 7.22 Titanium mesh sellar reconstruction. Coronal
T1-weighted MRI shows sheets of titanium mesh (arrows)
along the floor of the sella
Fig. 7.23 Expected early posteroperative sinonasal find-

ings after transsphenoidal surgery. Axial CT image shows
fluid in the bilateral maxillary sinus and bialteral nasal
stens
Fig. 7.24 Granulation tissue after transsphenoidal sur-

gery. Preoperative coronal contrast-enhanced T1-weighted
MRI (a) shows a pituitary adenoma. Postoperative con-
trast-enhanced T1-weighted MRI (b) obtained 3 months
after surgery shows heterogeneously enhancing tissue
in the sella (arrow). Postoperative contrast-enhanced
T1-weighted MRI (c) obtained 1 year after surgery shows
near resolution of the enhancing material in the sella
a b
Fig. 7.25 Subtotal pituitary macroadenoma resection. without mass effect upon the optic apparatus. There is fat
Coronal T1-weighted (a) and post-contrast fat-suppressed packing in the sella, which drops in signal with fat sup-
T1-weighted (b) MR images show enhancing residual pression in contradistinction to the residual tumor, which
tumor extending into the left cavernous sinus (arrow), enhances
7.4 Transsphenoidal Resection Malposition or migration of packing material

Complications for transsphenoidal resection is uncommon.
The displaced packing material can exert mass
7.4.1 Discussion effect upon the optic chiasm, resulting in visual
symptoms that may differ from the preoperative
Sellar hematomas are not uncommon after trans- deficits (Fig. 7.28). Alternatively, the packing
sphenoidal resection. When large, these can material can extend posteriorly and compress
cause mass effect upon surrounding structures the brainstem (Fig. 7.29). Such complications
and produce symptoms. Subacute hematomas in can be readily demonstrated on multiplanar
the sella can display high signal on T1- and CT or MRI. However, in some cases, displace-
T2-weighted MRI sequences and should not be ment of packing material can potentially mimic
mistaken for fat graft or residual tumor (Fig. 7.26). tumor invasion.
Gradient echo (GRE) or susceptibility-weighted Mucosal inflammation is fairly common
imaging (SWI) techniques can sometimes be use- after transsphenoidal resection and most com-
ful for identifying blood products on MRI, monly involves the sphenoid sinuses (Fig. 7.30).
although susceptibility effects from air in the On the other hand, mucocele formation after
adjacent sphenoid sinus can limit assessment. transsphenoidal resection is a rare or perhaps
Arterial injury during transsphenoidal resec- under-reported complication. Scar tissue can
tion is uncommon, but can manifest as pseudoan- obstruct the egress of mucous secretions, result-
eurysm and/or subarachnoid hemorrhage, which ing in their accumulation. On MRI, mucoceles
can lead to vasospasm. Most arterial complica- are often homogeneously iso- to hyperintense
tions related to transsphenoidal surgery involve on T1- and T2-weighted sequences and display
the internal carotid artery, but the ophthalmic, peripheral enhancement. These may sometimes
posterior communicating, and anterior cerebral be multilocular. The main differential consid-
arteries may also be affected. Arterial injury may eration is a postoperative hematoma, although
occur during dural opening, tumor resection, or these can be distinguished by their time course.
reconstruction of the sinuses and may be predis- Hematomas tend to resorb over time, while
posed by anatomic variants of the sinuses and mucoceles persist or even expand. Susceptibility-
internal carotid arteries and large tumors that weighted imaging can also be helpful, whereby
involve the cavernous sinus. Therefore, meticu- hematomas are hypointense, while mucoceles do
lous preoperative planning with imaging is not. Postoperative mucoceles can cause symp-
important for minimizing arterial injury. toms, such as headache and diplopia, but they can
Once arterial injury is suspected during trans- be successfully treated via incision and drainage.
sphenoidal resection, angiography is essential Although prophylactic antibiotics are rou-
for identifying the presence of pseudoaneu- tinely given before transsphenoidal surgery, the
rysms. The speculum and packing material may incidence of postoperative meningitis is in the
be kept within the sphenoid sinus in order to pre- range of 0.4–9%. This complication can manifest
vent exsanguination, and excess packing may as leptomeningeal enhancement in the basilar
result in arterial stenosis or occlusion. cistern region on MRI (Fig. 7.31). The presence
Endovascular control of bleeding may be of postoperative cerebrospinal fluid leakage is an
achieved by either balloon occlusion or coil important risk factor for meningitis after transs-
embolization of the affected internal carotid phenoidal surgery.
artery, coil embolization of the pseudoaneurysm, Cerebrospinal fluid leak is a known complica-
or stenting alone of the affected segment of the tion of transsphenoidal resections. This is a serious
internal carotid artery (Fig. 7.27). Peritumoral complication that can predispose to meningitis and
hemorrhage can lead to delayed cerebral vaso- intracranial hypotension. The beta-2-transferrin
spasm and associated progressive worsening assay is an accurate test for confirming the pres-
neurological deficits. ence of cerebrospinal fluid leaks. Imaging also
plays an important role in the workup of cerebro- T1-weighted images (Fig. 7.33). In addition,
spinal fluid leak: it is used to confirm the diagnosis, an ectopic posterior pituitary bright spot can be
localize the site of cerebrospinal fluid leak, identify observed in this condition.
a potential cause, and help plan surgical repair. Ptosis of the optic chiasm is not an uncommon
Several imaging modalities are available to evalu- finding following pituitary tumor resection. This
ate cerebrospinal fluid leak, including high-resolu- phenomenon tends to occur when a large portion
tion CT, CT cisternography, MRI, and radionuclide of the pituitary sella contents have been evacu-
cisternography (Fig. 7.32). However, high-resolu- ated resulting in a nearly or completely empty
tion CT is the first-line imaging modality and can sella (Fig. 7.34). Ptosis is recognized by a convex-
correctly predict the site of cerebrospinal fluid leak down configuration of the optic chiasm on a cor-
in over 90% of cases. When beta-2 transferrin is onal or sagittal plane. When severe, this condition
positive and high-resolution CT demonstrates a has the potential to cause visual deficits. The
single bony defect without any sign of encephalo- problematic empty sella with optic chiasm ptosis
cele, no other imaging is necessary. CT cisternog- can be treated via chiasmopexy. This procedure
raphy is reserved for patients with a negative consists of supporting the optic chiasm in near-
high-resolution CT or multiple bony defects and anatomic position via transsphenoidal Silastic
active cerebrospinal fluid leakage. The sensitivity struts and coils, among other materials (Fig. 7.35).
of CT cisternography is only about 50% in patients Acute visual loss related to transsphenoidal sur-
with intermittent cerebrospinal fluid leak. MR cis- gery can result from infarction of the optic appa-
ternography should be performed if high-resolu- ratus if the blood supply is disrupted during
tion CT shows a bony defect with an associated tumor resection. This can be assessed on coronal
soft tissue opacity in order to exclude the possibil- T2-weighted MRI, which may show new signal
ity of meningocele or encephalocele. Contrast- abnormality in the optic apparatus (Fig. 7.36).
enhanced sequences are useful for detecting dural Fibrosis following transsphenoidal pituitary
enhancement at the site of the leak. Nuclear cister- surgery is not an uncommon finding on postop-
nography using In-111 is sometimes performed for erative MRI. Fibrosis can manifest as linear or
complex cases and to help determine whether there amorphous areas within the sella. The imag-
is indeed a cerebrospinal fluid leak. ing appearance is often indistinguishable from
A variety of endocrinological disturbances implant materials or residual tumor. Occasionally,
can occur after transsphenoidal resection. In the adhesion bands form that extend across the sella
acute postoperative setting, a minority of patients or diaphragm to the brain or residual tumor.
experience diabetes insipidus. This is associated Adhesions appear as linear structures with low to
with absence of the posterior pituitary bright intermediate signal intensity on T1-weighted and
spot on imaging. On the other hand, hyponatre- T2-weighted MRI sequences and enhance less
mia related to transsphenoidal surgery tends to and/or slower than the pituitary stalk (Fig. 7.37).
have a delayed onset. Panhypopituitarism can These adhesions can hamper subsequent surgi-
result from transection of the hypophysis. This cal resection of residual tumor. Fibrosis may also
can best be evaluated using high-resolution prevent normal pituitary gland re-expansion and
MRI sequences, such as CISS and thin-section cause stalk deviation.
a b
Fig. 7.26 Postoperative hematoma. Coronal T2-weighted (a), T1-weighted (b), and post-contrast T1-weighted (c) MR
images show the intrinsically hyperintense fluid collection in the sella (arrows) after recent transsphenoidal surgery
a b
c d
Fig. 7.27 Carotid artery injury. Preoperative coronal post- speculum. Digital subtraction carotid angiograms show a
contrast T1-weighted MRI (a) shows a large pituitary ade- right cavernous carotid pseudoaneurysm (arrow) adjacent
noma that extends into the cavernous sinuses. Postoperative to the speculum (d). The pseudoaneurysm was s uccessfully
scout (b) and axial CT image (c) show transsphenoidal treated via endovascular coiling (e)
a a
Fig. 7.28 Suprasellar fat graft compressing the optic chi-

asm. Within an hour of arrival in the recovery room after
transsphenoidal pituitary resection, the patient was found
to have new visual deficits, different from the preoperative
symptoms. Sagittal CT image (a) and sagittal T1-weighted
MRI (b) show the fat graft (arrows) extending into the
suprasellar space. Pneumocephalus is also present
Fig. 7.29 Merocel migration and brainstem compres-

sion. Axial CT image (a) shows low-intensity sponge-like
material posterior to the sella that compresses the brain-
stem (arrow). Similarly, the sagittal T2-weighted MRI (b)
shows the spongy hypointense packing material extending
posteriorly, exerting mild mass effect upon the brainstem
(arrow)
a b
Fig. 7.30 Sinus inflammation. The patient presented macroadenoma (*) but a clear sphenoid sinus.
with symptoms of congestion following transsphenoidal Postoperative sagittal post-contrast coronal T1-weighted
pituitary adenoma resection. Preoperative sagittal MRI (b) demonstrates complete extensive mucosal thick-
contrast-enhanced T1-weighted MRI (a) shows a pituitary ening of the sphenoid sinus (arrow)
Fig. 7.31 Postoperative infection. Axial post-contrast

fat-suppressed T1-weighted MRI shows diffuse lepto-
meningeal enhancement centered about the basal cisterns
due to meningitis
a b
Fig. 7.32 Cerebrospinal fluid leak. The patient under- meningocele and spillage of contrast into the sphenoid
went transsphenoidal resection of a pituitary adenoma. sinus (arrow). The patient was scanned in a prone position
Approximately 1 week after surgery, the patient presented in order to direct a maximum amount of contrast to the
with a cerebrospinal fluid leak. Oblique coronal CT (a) site of suspected cerebrospinal fluid leakage. Nuclear
cisternogram image with the patient scanned in a prone medicine cisternogram (b) also shows radiotracer activity
position shows pooling of contrast around the fat graft that localizing to the paranasal sinuses (arrow). Cerebrospinal
has partially herniated inferiorly into the sphenoid sinus fluid was also seen percolating around the fat graft during
through a bony defect in the floor of the sella with a the subsequent surgery
Fig. 7.33 Pituitary stalk transection. The patient is status

post-transsphenoidal decompression of sellar/suprasellar
Rathke’s cleft cyst complicated by transection of the pitu-
itary stalk and secondary panhypopituitarism. The thick-
slab sagittal MIP T1-weighted MRI shows interruption of
the infundibulum (arrow)
Fig. 7.35 Chiasmopexy. Coronal CT image shows a strip

of Silastic (arrow) in the sella, which was used to support
a sagging optic chiasm
Fig. 7.34 Optic chiasm ptosis. Preoperative coronal

T2-weighted MRI (a) shows a large macrocystic pitu-
itary adenoma that uplifts the optic chiasm (arrow).
Postoperative coronal T2-weighted MRI (b) demonstrates Fig. 7.36 Optic nerve ischemia. The patient presented
ptosis of the optic chiasm (arrow) into an otherwise empty with new visual deficits after transsphenoidal surgery.
sella Coronal T2-weighted MRI shows hyperintensity and
swelling of the right optic chiasm (arrow)
a b
Fig. 7.37 Postoperative fibrosis. Axial T2-weighted (a) and post-contrast T1-weighted (b) MR images show an
intermediate intensity band (arrows) traversing the sella anterior to the pituitary stalk
7.5 iddle Cranial Fossa

M grafts, and pericranial flaps, often in combination
Reconstruction (Figs. 7.38, 7.39, and 7.40). Titanium mesh recon-
struction is particularly useful for reproducing the
7.5.1 Discussion natural contours of the middle cranial fossa thereby
providing good cosmetic results. The incidence of
Reconstruction of the middle cranial fossa can complications secondary to these reconstruction
be performed using titanium mesh, bone grafts, techniques is generally low, but includes instabil-
hydroxyapatite cement, free flaps (most commonly ity of the repair, encephalomalacia, cerebrospinal
fat or myocutaneous), temporalis muscle or fascia fluid leaks, infection, and lesion recurrence.
a b
Fig. 7.38 Middle cranial fossa reconstruction with tita- the left temporomandibular joint that erodes into the mid-
nium mesh and bone graft. The patient underwent middle dle cranial fossa. Postoperative coronal (b, c) CT images
cranial fossa reconstruction with mesh and bone graft for demonstrate interval resection of the tophus. There is
resection of TMJ pseudogout. Preoperative coronal post- reconstruction of the middle fossa floor with a titanium
contrast T1-weighted MRI (a) shows a large mass (*) in plate and bone graft
a b
Fig. 7.39 Middle cranial fossa reconstruction with myo- myocutaneous flap. Axial CT images in the soft tissue (a)
cutaneous flap. The patient has a history of recurrent glio- and bone (b) windows demonstrate resection of a portion
blastoma involving the left middle cranial fossa. of the left middle cranial fossa skull base and application
Reconstruction was performed using a rectus abdominis of a myocutaneous flap
a b
Fig. 7.40 Middle cranial fossa reconstruction with fat bone graft positioned in right the middle cranial fossa for
and bone grafts. Coronal CT (a) image and coronal treatment of a postoperative cerebrospinal fluid leak
T1-weighted MRI (b) show fat graft (arrows) as well as
7.6 Surgical Approaches tissue. This enhancement usually lasts up to

for Vestibular Schwannoma 1–2 years and tends to be linear and diffuse, but it
Resection can also have a “whorled” appearance. Often, the
fat graft shrinks over time, losing its triangular
7.6.1 Discussion configuration and allowing air or fluid to enter
the mastoid bowl.
Several surgical approaches can be used to resect The retrosigmoid approach for cerebellopon-
vestibular schwannomas, including the middle tine angle tumors consists of creating a bone flap
cranial fossa approach, the translabyrinthine and performing a dural incision over the ipsilat-
approach, and the retrosigmoid approach. eral cerebellar hemisphere, posterior to the sig-
The middle cranial fossa approach for cere- moid sinus and inferior to the transverse sinus.
bellopontine angle and perimesencephalic tumors The mastoid air cells are commonly entered, and
consists of temporal craniotomy, extradural tem- bone wax is applied along the edges in order to
poral lobe retraction, dissection of the petrous prevent leakage of cerebrospinal fluid. The cer-
ridge dura, and drilling of the roof of the internal ebellar hemisphere is retracted medially, and the
auditory canal, which is covered with a fascia or medial portion of the posterior internal auditory
fat graft after the tumor is resected. The main canal wall is resected, once the intracranial por-
advantages of this approach include a higher like- tion of the tumor is resected. However, an inter-
lihood of hearing preservation and access to the nal labyrinthectomy is often necessary in order to
fundus of the internal auditory canal for small access the fundus of the internal auditory canal.
intracanalicular tumors. Overall, this approach Fat graft is also sometimes inserted into the cer-
carries a higher risk for facial nerve injury, and ebellopontine angle region if air cells are encoun-
retraction injury resulting in temporal lobe glio- tered in the wall of the resected medial internal
sis is found in most patients on follow-up imag- auditory canal. Occasionally, prominence of the
ing (Fig. 7.41). This approach also has limited cerebrospinal fluid lateral to a flattened cerebel-
applicability for the resection of large tumors but lar hemisphere results from retraction and often
can be combined with the retrosigmoid approach gradually dissipates over time (Fig. 7.43).
in selected cases. Although there is no consensus for when to
The translabyrinthine approach provides max- obtain baseline postoperative imaging, it is gen-
imal exposure to the cerebellopontine angle, erally recommended that this is performed
although it sacrifices hearing capacity. This between 6 months and 1 year. Patients with
approach is used to resect intralabyrinthine, intra- known subtotal resection, nodular or mass-like
cochlear, and larger cerebellopontine angle enhancement in the internal acoustic canal, or a
tumors, as well as vestibular schwannomas in history of neurofibromatosis type II undergo
cases where hearing is poor or has been lost. The serial imaging thereafter. Residual tumor is delib-
translabyrinthine approach entails complete mas- eratively left in some cases, particularly in the
toidectomy and labyrinthectomy with fat graft lateral internal auditory canal, which is difficult
packing. In addition, the sigmoid sinus, tegmen to access via a retrosigmoid approach, in order to
tympani, and portions of the internal auditory minimize the risk of facial nerve and vascular
canal can be skeletonized. The ossicles are some- injury. Fat-suppressed post-contrast T1-weighted
times removed, and packing material is left in the MRI sequences are particularly useful for the
middle ear cavity in order to minimize cerebro- evaluation of tumor (Fig. 7.44).
spinal fluid leakage. Fat grafts are typically used Various surgical complications can be encoun-
to fill the mastoidectomy bowl, middle ear, and tered on postoperative imaging. For example, fat
sometimes the internal auditory canal (Fig. 7.42). grafts can undergo necrosis, which may appear as
On post-contrast MRI sequences, enhancement cystic change within and adjacent to the residual
along the periphery of the fat graft is typical and fat graft (Fig. 7.45). Rarely, aseptic lipoid men-
likely attributable to the presence of granulation ingitis can result from fragmentation and dis-
persal of the fat graft in the subarachnoid space niation of the cerebellum into the surgical cav-
(Fig. 7.46). Other complications may include ity (Fig. 7.49), endolymphatic sac fenestration
leakage of cerebrospinal fluid into the mastoid with loss of T2 signal (Fig. 7.50), infectious
air cells and middle ear (Fig. 7.47), particularly of inflammatory labyrinthitis (Fig. 7.51), laby-
in patients with overpneumatized air cells that rinthitis ossificans (Fig. 7.52), wound infection
are transgressed by the surgical approach, pseu- (Fig. 7.53), territorial infarction (Fig. 7.54), and
domeningocele from leakage of cerebrospinal venous sinus thrombosis (Fig. 7.55).
fluid into the overlying scalp (Fig. 7.48), her-
a b
Fig. 7.41 Middle cranial fossa approach. Axial FLAIR middle cranial fossa approach for cerebellopontine angle
(a) and coronal post-contrast T1-weighted (b) MR images schwannoma resection. Sequelae of translabyrinthine
demonstrate encephalomalacia and volume loss in the resection are also noted on the left side without associated
right inferior temporal lobe (arrows) ipsilateral to the brain parenchymal injury
a b
Fig. 7.42 Translabyrinthine approach with fat graft canals, but the right cochlea remains intact. Granulation
reconstruction. Axial CT (a) and T1-weighted MRI (b) tissue enhancement. Axial contrast-enhanced fat-saturated
show obliteration of the internal auditory canal and mas- T1-weighted MRI (d) shows linear enhancement along the
toid bowl with fat graft. The axial T2-weighted MRI (c) periphery of the fat graft (arrow) and along the overlying
shows absence of the right vestibule and semicircular incision plane, which likely represents granulation tissue
Fig. 7.43 Retrosigmoid approach. Axial T2-weighted

MRI shows prominent extra-axial cerebrospinal fluid
adjacent to the flattened edge of the right cerebellar hemi-
sphere, which is attributable to intraoperative retraction of
the cerebellum
a b
Fig. 7.44 Residual schwannoma. Axial pre- (a) and post-contrast (b) T1-weighted MR images show enhancing tumor
in the left cerebellopontine angle cistern (arrow) and fat graft along the surgical approach
a b
Fig. 7.45 Fat graft necrosis. Axial CT image (a), axial T2-weighted (b), and T1-weighted (c) MR images show bands
of fluid within the left translabyrinthine fat graft
a b
Fig. 7.46 Fat graft aseptic lipoid meningitis. Axial (a, b) the suprasellar cistern, which represent fragments of the
T1-weighted MR images demonstrate numerous high T1 fat graft used during translabyrinthine resection
signal foci scattered in the subarachnoid spaces including
Fig. 7.47 Mastoid entry and cerebrospinal fluid leak.

The patient presented with cerebrospinal fluid otorrhea
after right acoustic schwannoma resection. Axial CT
image shows left retrosigmoid craniotomy traverses the
left mastoid air cells. There is opacification of the remain-
ing left mastoid air cells and middle ear, which was not
present prior to surgery
a b
Fig. 7.48 Pseudomeningocele. Axial T2-weighted (a) signal characteristics and extends far superiorly within
and coronal (b) T1-weighted MR images show the large the subgaleal space
subgaleal fluid collection (*) that has cerebrospinal fluid
Fig. 7.49 Encephalocele is a rare complication of the

translabyrinthine approach. Coronal post-contrast
T1-weighted MRI shows a dural defect through which the
right cerebellar hemisphere (encircled) herniates into the
translabyrinthine resection site, facilitated by shrinkage of
the fat graft
a b
Fig. 7.50 Postoperative endolymphatic sac fluid signal structures. Postoperative axial T2-weighted MRI (b)
loss. Preoperative axial T2-weighted MRI (a) shows a shows interval resection of the mass. There is diminished
large left vestibular schwannoma with mass effect on the signal within the left cochlea, labyrinth, and semicircular
pons and middle cerebellar peduncle, which are otherwise canals (encircled)
intact. There is normal signal within the bilateral inner ear
a b
Fig. 7.51 Labyrinthitis. Axial pre- (a) and post-contrast (b) T1-weighted MR images show avid enhancement of the
labyrinthine structures (arrow)
Fig. 7.52 Labyrinthitis ossificans. Axial CT image dem-

onstrates sclerosis of the right cochlea (arrow) following
translabyrinthine surgery
a b
Fig. 7.53 Wound abscess. Axial T2-weighted (a), axial and an area of restricted diffusion in the right translabyrin-
(b) and coronal (c) post-contrast T1-weighted, and ADC thine resection site (arrows)
map (d) show a rim-enhancing fluid collection with debris
a b
Fig. 7.54 Infarction. Axial T2 FLAIR MRI (a) shows high signal in the left lateral pons, middle cerebral peduncle, and
portions of the lateral cerebellar hemisphere. The corresponding ADC map (b) shows restricted diffusion
a a
Fig. 7.55 Venous sinus thrombosis. Axial (a) and coronal (b) CT venogram images show a filling defect in the left
transverse sinus adjacent to the retrosigmoid craniotomy (arrows)
7.7 adiosurgery for Vestibular

R Development of high T2 signal intensity in the
Schwannomas adjacent brain parenchyma occurs in about 30%
of cases. Transient loss of enhancement and cen-
7.7.1 Discussion tral necrosis are also common. The presence of
tumor necrosis and alterations in enhancement
Radiosurgery can be administered as a noninva- properties do not necessarily correlate with clini-
sive, image-guided treatment for selected cases cal outcome. Although the changes in contrast
of vestibular schwannomas. The technique con- enhancement are not predictive of clinical out-
sists of applying high-dose photon radiation come, imaging follow-up is recommended in
to the lesion from different angles. The treated order to differentiate true ongoing tumor progres-
tumors may continue to increase in size for up sion from transient treatment-related swelling.
to 2 years, followed by regression (Fig. 7.60).
a b
Fig. 7.56 Radiosurgery for vestibular schwannoma. (b) shows interval central non-enhancement within the
Preoperative axial contrast-enhanced T1-weighted MRI mass (arrow). There is also decrease in size and mass
(a) shows a large right cerebellopontine mass. effect on the right middle cerebellar peduncle and
Postoperative axial contrast-enhanced T1-weighted MRI brainstem
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Compan A, Rossi M, Pompilio M, Solero CL (2006) (2001) Pituitary adenomas: early postoperative MR
Craniofacial resection for malignant tumours involv- imaging after transsphenoidal resection. AJNR Am
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Imaging of the Postoperative Ear
and Temporal Bone 8
Daniel Thomas Ginat, Gul Moonis,
Suresh K. Mukherji, and Michael B. Gluth
8.1 Osseointegrated Bone transcranial bone conduction of sound to the con-

Conduction Hearing tralateral normal functioning cochlea.
Implants The traditional forms of these devices con-
sist of a titanium screw-like implants anchored
8.1.1 Discussion into the squamous portion of the temporal bone,
as well as percutaneous external flange fixture
Osseointegrated bone conduction hearing abutments to which removable sound proces-
implants (BAHA, Cochlear Corporation, sors/vibrators will attach. However, in newer
Australia and Ponto, Oticon Corporation, versions, these devices may lack a percutane-
Sweden) are implantable hearing devices used in ous component and instead feature a magnetic
patients with conductive, mixed, or unilateral disk that is attached to the osseointegrated
sensorineural hearing loss who cannot wear tra- screw completely contained just under the scalp
ditional air-conducting hearing aids. These (BAHA Attract, Cochlear Corporation,
devices function in conductive hearing loss by Australia), working via transcutaneous passage
direct transmission of sound via bone conduction of sound vibration. All of these osseointegrated
to the ipsilateral inner ear, bypassing the external hearing implants can be identified on imaging
auditory canal and middle ear. In unilateral pro- with a typical implant depth of 3–4 mm into the
found sensorineural hearing loss, they work by cortex of the skull (Fig. 8.1). However, the
magnetic component of newer non-percutane-
ous versions will generate a lot of imaging
D.T. Ginat, M.D., M.S. (*) artifact. All osseointegrated hearing implants
Department of Radiology, University of Chicago, that have been approved for use in the USA are
Chicago, IL, USA MRI compatible when the external sound pro-
cessor is removed. The most common compli-
G. Moonis, M.D. cation of these devices is adjacent soft tissue
and skin reactions resulting in cellulitis or
New York, NY, USA
infection. Other complications include loss of
S.K. Mukherji, M.D., M.B.A., F.A.C.R.
osseointegration due to adjacent bone necrosis
Department of Radiology, Michigan State University,
East Lansing, MI, USA which can result in screw loosening and extru-
sion. Intracranial abscess has also been
M.B. Gluth, M.D.
Department of Surgery, Division of Otolaryngology, reported, but this is a rare complication of
University of Chicago, Chicago, IL, USA BAHA implantation.

DOI 10.1007/978-3-319-52341-5_8
a b
Fig. 8.1 The patient has a history of conductive hearing and the overlying abutment (arrowhead). Photograph of
loss due to aural atresia. Lateral scout image (a) shows the BAHA device components (c) (Courtesy of Cochlear
BAHA device in position (arrow). Axial CT image (b) Corp)
shows the screw embedded in the temporal bone (arrow)
8 Imaging of the Postoperative Ear and Temporal Bone 353
8.2 Auriculectomy formed if there is extension of tumor from the

outer pinna into the external auditory canal.
8.2.1 Discussion Depending upon the extent of resection, the
resulting surgical defect can be closed primarily
Auriculectomy consists of resection of all or (Fig. 8.2) or via a variety of reconstruction tech-
part of the pinna. This procedure is usually per- niques using skin grafts or soft tissue flaps
formed for resection of external ear cutaneous (Fig. 8.3), for example. Furthermore, auricular
malignancies, such as basal cell carcinoma or prostheses can also be applied for cosmetic pur-
squamous cell carcinoma. Parotidectomy and poses, and these may be held in place with
neck dissection may be performed in conjunc- osseointegrated magnetic implants (Vistafix,
tion with auriculectomy if there is extension of Cochlear Corporation, Australia). Ultimately,
tumor along the fascial planes or if regional postoperative imaging, particularly CT or MRI,
lymph node metastasis is suspected. In addition, is typically obtained to evaluate for tumor recur-
lateral temporal bone resection is often per- rence in this group of patients.
Fig. 8.2 Auriculectomy. Axial CT image (a) shows a

right auricular squamous cell carcinoma (arrow). a
Postoperative axial CT image (b) shows complete
absence of the right auricle
b
Fig. 8.3 Auricular reconstruction with rib graft. Axial

(a) and 3D (b) CT images show cartilage and bone a
fragments within the remodeled right auricle
b
8.3 Auricular Reconstruction stable alloplastic implant material that can inte-
grate with host tissues and is relatively resistant
8.3.1 Discussion to infection. For auricular reconstruction, the
prosthesis is enveloped in a temporoparietal fas-
Ear reconstruction is performed to reproduce the cial flap with full-thickness skin graft coverage in
normal appearance of the auricle for conditions order to provide good cosmetic results and mini-
such as microtia. Autogenous rib cartilage recon- mize the risk of implant extrusion. On CT,
struction has been one of the more traditional Medpor ear prostheses demonstrate attenuation
methods. The cartilage grafts often appear calci- values between fat and soft tissue and are shaped
fied (Fig. 8.3). High-density porous polyethylene to resemble the natural morphology of the auricle
(Medpor) is a more recent option. Medpor is a (Fig. 8.4).
Fig. 8.4 Auricular reconstruction with porous

polyethylene. Coronal (a) and sagittal (b) CT images a
show a low-attenuation left auricular implant that has
near-anatomic configuration
b
8.4 Canaloplasty postoperative imaging and should not be mistaken

and Meatoplasty for pathology. Complications of canaloplasty
include canal restenosis, temporomandibular joint
8.4.1 Discussion violation, osteonecrosis, and facial nerve palsy—
especially if the distal aspect of the mastoid por-
Canaloplasty and meatoplasty consist of surgi- tion of the facial nerve courses lateral to the
cally widening the bony external auditory canal tympanic annulus thereby being at risk of drill
and soft tissue/cartilaginous meatus, respectively. trauma in the posterior-inferior aspect of the
This can be performed for treating congenital or external auditory canal. If persistent pain, trismus,
acquired canal stenosis and other lesions such as or delayed healing is encountered after canalo-
exostoses. Canaloplasty is also often performed plasty, radiologic assessment of the integrity of
as part of a transcanal approach in order to the anterior canal wall is made to determine if the
augment surgical exposure during middle ear sur- temporomandibular joint has been violated and
gery. Meatoplasty is often performed in conjunc- assessment of whether this has resulted in a pro-
tion with canal wall down mastoidectomy to lapse of joint capsule into the canal lumen.
provide postoperative access to the resultant mas- Chronic otitis externa and failed epithelialization
toid cavity for evacuation of debris in the office. after canaloplasty may suggest the possibility of
The resulting appearance on CT is an external iatrogenic osteonecrosis from excessive burning
auditory canal with a relatively capacious lumen of the bone by a drill bur that was applied with
(Fig. 8.5). In particular, thinning, irregularity, and/ insufficient irrigation, which will appear as a lytic
or flattening of the bone, soft tissue thickening, defect on CT.
and bony wall defects are common findings on
Fig. 8.5 Canaloplasty and meatoplasty. Coronal CT

image shows a capacious meatus and external auditory
canal with straightening of the floor and loss of the infe-
rior tympanic sulcus
8.5 Atresiaplasty fascia, and the external auditory canal is often

lined with split-thickness skin grafts (Fig. 8.6).
8.5.1 Discussion Complications of the procedure include external
auditory canal restenosis, lateralization and per-
Atresiaplasty consists of creating an external foration of the tympanic membrane, ossicular
auditory canal and tympanic membrane in order chain refixation, sensorineural hearing loss, facial
to restore hearing in selected patients with con- nerve injury, and cholesteatoma, usually in the
genital external aural atresia. An opening is created external auditory canal, which appears as
drilled through the atresia plate, a new tympanic globular soft tissue on CT, sometimes with asso-
membrane is usually created using temporalis ciated bone erosions (Fig. 8.7).
Fig. 8.6 Atresiaplasty. Preoperative axial (a) and

coronal (b) CT images show bony atresia of the a
left external auditory canal with intact ossicles.
Postoperative axial (c) and coronal (d) CT images
show interval resection of the atretic plate and
partial mastoidectomy, resulting in a passage that
communicates with the exterior and neotympanic
membrane
b
d Fig. 8.7 Cholesteatoma after atresiaplasty. Coronal CT

image shows soft tissue material (arrow) within the surgi-
cally created external auditory canal, which proved to be a
cholesteatoma. There is also scar tissue that tethers the
ossicular prosthesis in an abnormal position
8.6 Myringotomy not confuse these with unintended foreign bodies

and Tympanostomy Tubes or ossicular dislocation. CT may also be per-
formed to confirm the presence of tympanostomy
8.6.1 Discussion tubes that are not readily visible on physical exam
and to evaluate for suspected complications, such
Tympanostomy tubes (pressure equalization as persistent effusions within the middle ear or
tubes) are commonly used to treat the manifesta- mastoid, cholesteatoma, or diffuse tympanoscle-
tions of Eustachian tube dysfunction including rosis (Fig. 8.11). Occasionally a tube may be
recurrent acute otitis media or chronic otitis media detected in the middle ear space due to a rare inci-
with effusion by providing an alternative outlet dence of medial migration, but more often a result
for middle drainage and intratympanic pressure of accidental loss of a tube within the middle ear
equalization via the external auditory canal. Tube during placement. Tympanostomy tubes are nor-
placement follows myringotomy, in which an mally expelled spontaneously from the tympanic
opening is made in the tympanic membrane. membrane after 3–24 months (Fig. 8.12) depend-
Tympanostomy tubes are available in a variety of ing on the design and shape of the particular tube
shapes, sizes, and materials, including plastics utilized. The main complications of tympanos-
and metals, which are readily apparent on CT tomy tubes include formation of a foreign body
(Figs. 8.8, 8.9, and 8.10). However, the presence granuloma on the tympanic membrane immedi-
of fluid or malpositioning may make identifica- ately adjacent to the tube or chronic otorrhea due
tion of these tubes difficult. The tubes may be to unresolved underlying chronic otitis media or
found incidentally on CT. Thus, recognizing tym- mastoiditis.
panostomy tubes on imaging is important as to
Fig. 8.9 Metal grommet. Axial CT image shows a metal

Fig. 8.8 Plastic grommet. Axial CT image shows a Teflon
grommet in the tympanic membrane
grommet appropriately situated across the tympanic
membrane
Fig. 8.10 Plastic shaft tympanostomy tube. Coronal CT

image shows a long shaft Teflon tube (arrow)
Fig. 8.12 Extrusion of tympanostomy tube. Axial CT
image shows a tympanostomy tube in the external audi-
tory canal (arrow)
Fig. 8.11 Medial dislocation of tympanostomy tube.

Axial CT image shows a tympanostomy tube in the hypo-
tympanum (arrow). Note the myringotomy, which appears
as a gap in the tympanic membrane
8.7 Myringoplasty progressive popularity among ear surgeons when

and Tympanoplasty dealing with chronic middle ear disease due to
their resistance to the effects of negative middle
8.7.1 Discussion ear pressure. Tympanoplasty grafts appear slightly
thicker than the normal native tympanic mem-
Myringoplasty is a simple procedure that is limited branes, especially if cartilage is utilized. However,
to tympanic membrane repair without exploration excessive thickness may signify scarring within
or manipulation of the middle ear space. the middle ear or postoperative myringitis. Silastic
Myringoplasty is most often applied to very small sheeting is sometimes implanted during tympano-
tympanic membrane defects caused by extruded plasty in order to prevent the formation of adhe-
tympanostomy tubes. In contrast, tympanoplasty sions as part of a staged surgical process wherein
involves reconstruction of the tympanic membrane removal is performed months later during a sec-
with concurrent middle ear exploration and possible ond-stage middle ear exploration and ossicular
ossicular chain reconstruction. Several types of chain reconstruction procedure.
tympanoplasty procedures can be performed, which High-resolution CT is the main imaging modal-
are depicted in Figs. 8.13, 8.14, 8.15, 8.16, 8.17, ity used for studying the architectural changes from
8.18, 8.19, and 8.20 and described in Table 8.1. tympanoplasty and evaluating suspected causes of
Among these, Type 1 and Type 3 tympanoplasties graft failure and persistent conductive hearing loss,
are overwhelmingly the most commonly performed. such as recurrent perforation, middle ear effusion,
Some forms of mastoidectomy may be performed tympanosclerosis affecting the ossicular chain, tym-
concurrent with tympanoplasty if chronic suppura- panic membrane lateralization, and tympanic mem-
tive otitis media and/or cholesteatoma is present. brane blunting. The latter two of these are more
The most common materials used for tympa- likely to be encountered if canaloplasty was per-
noplasty include autologous temporalis fascia and formed at that same time as tympanic membrane
auricular cartilage grafts—with the later gaining repair or if the malleus has been completely removed.
Fig. 8.13 Type I tympanoplasty with temporalis

fascia. The patient has a history of long-standing a
right-sided tympanic membrane perforation. Since the
patient was a possible candidate for cochlear
implantation, repair of the tympanic membrane
perforation was necessary. Preoperative axial CT
image (a) demonstrates a perforation of the right
tympanic membrane. Axial CT image obtained after
tympanoplasty (b) shows a tympanic membrane graft
composed of temporalis fascia, which is slightly
thicker than native tympanic membrane
b
Fig. 8.15 Type I tympanoplasty with silastic implant for

Fig. 8.14 Type I tympanoplasty with cartilage graft. preventing adhesions. Axial CT image shows the implant
Axial CT image shows the reconstructed posterior portion (arrow) inserted into the middle ear cavity, medial to the
of the left tympanic membrane as a thick sheet (arrow). reconstructed tympanic membrane (arrowhead)
Note the relative thickness of the normal anterior portion
of the tympanic membrane
Fig. 8.16 Iatrogenic intratympanic cholesteatoma fol-

lowing tympanoplasty. Coronal CT image shows expans-
ile soft tissue (arrow) along the inferior tympanic annulus, Fig. 8.17 Type II tympanoplasty. Coronal CT image
splaying the tympanic membrane graft shows the long process of the incus (arrow) in contact
with the tympanic membrane graft
Fig. 8.18 Type III tympanoplasty minor columella with

bone strut. Coronal CT image shows a bone graft (arrow)
interposed between the tympanic membrane and stapes Fig. 8.20 Type IV tympanoplasty. Coronal CT image
head shows the tympanic membrane graft applied to the stapes
footplate such that the footplate is exteriorized into the
mastoid cavity and external auditory canal. Note the small
middle ear space (cavum minor) created during Type IV
tympanoplasty
Fig. 8.19 Type III tympanoplasty stapes columella.

Axial CT image demonstrates a reconstructed tympanic
membrane with cartilage graft applied directly to the head
of the stapes (encircled)
Table 8.1 Wullstein classification of types of tympanoplasty

Type Description Diagram
I Repair of the tympanic membrane without
altering the ossicles. Most common type
performed
II Repair of the tympanic membrane with

drumhead reconstructed onto intact incus
(malleus usually absent). This procedure is
only rarely performed
III Repair of the tympanic membrane and

ossicular chain in a manner that couples the
stapes to the drumhead. Variations include
minor columella (usually a PORP prosthesis or
sculpted incus interposition autograft) where
drumhead is connected to intact stapes
superstructure major columella, usually a
TORP prosthesis, where the drumhead is
connected to stapes footplate without intact
superstructure, or stapes columella where
drumhead is placed directly upon the intact
stapes superstructure
(continued)
Table 8.1 (continued)
Type Description Diagram
IV Tympanic membrane repair graft is applied
directly to the stapes footplate such that it is
exteriorized into the ear canal while shielding
of the round window niche using a thick graft,
resulting in small middle ear space termed
cavum minor. Usually performed along with
canal wall down mastoidectomy
V Same as type IV tympanoplasty except stapes

footplate is removed and oval window is sealed
with soft tissue graft. Performed when the
stapes footplate is ankylosed
8.8 Ossicular Interposition incus is positioned in contact with the stapes

footplate, and the notched short process is posi-
8.8.1 Discussion tioned below the manubrium (notched incus with
long process); however, results of incus interpo-
Ossicular interposition grafting is a form of sition are much poorer if the stapes superstruc-
ossicular reconstruction (Type 3 tympanoplasty ture is absent and the technique is only rarely
mechanism) that consists of resecting the malleus utilized. The malleus head can also be used as an
head or incus and then reinserting it between the interposition graft by drilling a small groove at
stapes and either the malleus manubrium or tym- the point where the head was amputated from the
panic membrane after it has been sculpted with a malleus neck, thereby allowing the graft to be set
drill bur. The most common form of this tech- securely between the stapes superstructure and
nique is incus interposition grafting, in which the the undersurface of the tympanic membrane.
long process is amputated and a notch is cut into Complications related to ossicular interposition
the short process such that it can be wedged include encasement by granuloma, iatrogenic
between the manubrium of the malleus and the cholesteatoma, graft necrosis (Fig. 8.22), and
stapes superstructure (Fig. 8.21). If the stapes graft dislocation (Fig. 8.23).
superstructure is absent, the long process of the
a b
Fig. 8.21 Incus interposition. Illustration of incus inter- disarticulation of the malleoincudal joint. Axial (c) and
position (a). Axial (b) CT image shows that only the mal- coronal (d) CT images show that the sculpted incus
leus is present in the epitympanic space due to (arrows) articulates with the head of the stapes
c d
Fig. 8.22 Osteonecrosis of incus interposition graft.

Axial CT image shows a demineralized incus interposi-
tion graft (arrow)
Fig. 8.23 Incus interposition dislocation. Coronal CT
image shows an air gap between the head of the stapes and
the remodeled incus (arrow)
8.9 Ossicular Reconstruction shaft. TORPs extend from the tympanic mem-
with a Synthetic Prosthesis: brane to the stapes footplate where a cylindrical
Partial Ossicular distal end of the shaft is set (Fig. 8.24).
Reconstruction Prosthesis Occasionally a separate “footplate shoe” prosthe-
(PORP), Total Ossicular sis is used in combination with a TORP to pre-
Reconstruction Prosthesis vent it from slipping off of the footplate, since
(TORP), Incudostapedial TORPs are often considered less secure than
Joint Reconstruction PORPs. A final class of incudostapedial joint
Prosthesis, and Vibrating reconstruction prosthesis exists to deal with the
Ossicular Reconstruction common scenario of isolated incus erosion
Prosthesis involving the long process—including its articu-
lation with the stapes superstructure. These pros-
8.9.1 Discussion theses can be observed spanning from the residual
incus long process to the stapes capitulum.
PORPs and TORPs are synthetic implants used However, synthetic hydroxylapatite bone cement
for ossicular chain reconstruction typically com- products are also commonly utilized for this pur-
posed of a head to engage the tympanic mem- pose. Selected examples of various prostheses
brane and a shaft to engage the stapes. Most are shown in Figs. 8.25, 8.26, 8.27, 8.28, and 8.29
modern prostheses are composed of dense and listed in Table 8.2.
hydroxyapatite, titanium, or some combination Vibrating ossicular reconstruction prostheses
of the two. Hydroxyapatite has the advantage of (VORPs) are part of an electronic implantable
being compatible with direct contact to the tym- hearing device (Vibrant Soundbridge, Med-El,
panic membrane, whereas titanium has a ten- Austria) that may be used to treat conductive
dency to erode through the drumhead if directly hearing loss in cases where the prognosis for a
in contact; therefore, an overlying protective car- favorable hearing outcome with a PORP or a
tilage cap is mandatory if a titanium head is uti- TORP is extremely poor, such as severe congeni-
lized and optional with hydroxylapatite. On CT, tal middle ear anomalies or end-stage middle ear
cartilage appears as a thickened segment of tym- disease. A VORP can also be used in cases of
panic membrane overlying the prosthesis. mixed hearing loss where the amplification needs
Plastipore, Teflon, polyethylene, stainless steel, are beyond the capability of a conventional hear-
gold, platinum, nitinol, and cortical bone have ing aid. VORPs consist of an external sound pro-
also been used. Some PORPs and TORPs feature cessor that is held magnetically over an implanted
a notched head that is intended to stabilize the receiver-stimulator located under the postauricu-
implant by engaging the malleus manubrium, lar scalp. The receiver-stimulator is connected by
while others are placed in direct contact with the a wire to a magnetic vibrating floating mass
posterior/superior quadrant of the tympanic transducer that is either connected to the ossicu-
membrane. PORPs extend to the head of the lar chain or placed directly onto the round win-
intact stapes and are set upon the superstructure dow membrane (Fig. 8.30).
with an open cradle located at the end of the
a b
Fig. 8.24 Schematics of PORP (a) and TORP (b). The tilage graft complex and the stapes footplate at the oval
PORP inserts between the tympanic membrane or carti- window. Photographs of various ossicular prostheses (c)
lage graft complex and the head of the stapes. In contrast, (Courtesy of Grace Medical)
the TORP inserts between the tympanic membrane or car-
Fig. 8.25 Cortical bone sculpted TORP. Coronal CT

image shows a linear bone fragment that extends between
the tympanic membrane cartilage graft and stapes
footplate
Fig. 8.27 Applebaum PORP. Axial (a) and coronal (b)

CT images show the characteristic hollow L-shaped
hydroxyapatite prosthesis, which articulates with the sta-
pes medially and incus laterally
Fig. 8.26 Goldenberg TORP. Coronal CT image shows

the flathead prosthesis attached to the tympanic mem-
brane with cartilage graft reconstruction and shaft well
seated upon the stapes footplate
Table 8.2 Examples of ossicular prostheses

Prosthesis Description
Applebaum Hydroxylapatite incudostapedial
joint reconstruction prosthesis
spanning from the incus long
process to stapes head. Features a
characteristic L-shaped configuration
Black oval top Available as PORP or
TORP. Features a bulky head with a
“horseshoe” or C shape
Dornhoffer Available as PORP or TORP with
notched hydroxylapatite head and a
titanium shaft
Goldenberg Available as PORP or
TORP. Triangular notched
hydroxylapatite head with off-
Fig. 8.28 Black oval-top PORP. Axial CT image shows centered Plastipore shaft
the tympanic membrane and tragal cartilage graft draped
over the C-shaped hydroxyapatite head of the prosthesis.
The piston of the prosthesis, which articulates with the
head of the stapes, is not conspicuous
Fig. 8.29 Dornhoffer PORP. Stenver reformatted CT

image shows the hydroxyapatite head in contact with the
reconstructed tympanic membrane and the titanium cradle
in contact with the stapes superstructure
a b
Fig. 8.30 VORP. The illustration (a) shows the compo- Axial CT image (b) shows the floating mass transducer in
nents of the VORP including the floating mass transducer the round window niche (arrow) (Courtesy of Christine
(arrow) in the round window niche attached to the incus. Toh, MD)
8.10 Stapedectomy, pes prostheses are available, but most fall into
Stapedotomy, and Stapes the categories of being either a bucket or pis-
Prosthesis ton (Fig. 8.31). Bucket prostheses are set just
under the lenticular process of the incus with
8.10.1 Discussion a small wire that secures it, while pistons usu-
ally consist of a smaller barrel and a wire that
Stapes reconstruction is performed for treatment is crimped around the long process (Figs. 8.32,
of conductive hearing loss in patients with otoscle- 8.33 and 8.34). Alternatively, stapes prostheses
rosis, stapes fracture, adhesions, or tympanoscle- can be attached to the malleus if the incus is not
rosis. Stapedectomy usually consists of resecting available for reconstruction (Fig. 8.35). Stapes
the entire stapes, while stapedotomy involves prostheses can be made from a variety of materi-
removing the superstructure and creating a small als including titanium, Teflon, fluoroplastic, and
hole into the stapes footplate. Stapedotomy often nitinol. Virtually all stapes prostheses are MRI
involves minimally traumatic surgical techniques, compatible, except for the McGee stainless steel
such as hands-free laser application. prostheses dating from 1987. Nevertheless, the
Stapes prostheses typically extend from the metal components of the prosthesis can produce
incus to the stapedotomy defect in the footplate susceptibility artifact that obscures detail of sur-
and ideally do not extend medially into the ves- rounding structures and can resemble labyrinthi-
tibule more than 0.25 mm. Several types of sta- tis ossificans (Fig. 8.36).
Fig. 8.31 Schematic of a

stapes piston prosthesis (a).
Photographs of piston and
bucket handle stapes
prostheses (b) (Courtesy of
Grace Medical)
Fig. 8.32 Robinson bucket handle prosthesis. Coronal

CT image shows a metallic prosthesis that extends from
the long process of the incus to the oval window, where Fig. 8.34 Smart nitinol wire piston prosthesis. Axial CT
there is beam-hardening artifact image shows the prosthesis in position (arrow) in contact
with the stapes footplate
Fig. 8.33 Schuknecht Teflon wire stapes piston prosthe-

sis. Axial CT image shows the filamentous prosthesis in
position (arrow)
a b
c d
Fig. 8.35 Stapedectomy with malleus grip prosthesis. Serial coronal CT images (a–d) demonstrate a wire prosthesis
(arrows) extending from the stapes footplate to the malleus
a b
Fig. 8.36 Susceptibility artifact from stapes prosthesis sponding axial CISS image (b) shows obscuration of a
mimicking labyrinthitis ossificans. Axial CT image (a) portion of the cochlea due to the artifact (encircled)
shows a large metallic Robinson prosthesis. The corre-
8.11 Ossicular Prosthesis fracture of the prostheses (Fig. 8.50). Prosthesis

Complications subluxation or dislocation is the most common
complication responsible for up to 60% of postop-
8.11.1 Discussion erative hearing loss and occurs most commonly in
the first 6–8 weeks before fibrosis occurs. Stapes
CT imaging may be obtained after ossicular prostheses most commonly displace posterior and
chain reconstruction if a poorer-than-expected inferior to the oval window. Alternatively, these
hearing outcome results in order to determine if prostheses can migrate into the vestibule, which
the prosthesis has slipped or if there is another can cause vertigo and possibly a concurrent peri-
potential cause of hearing loss such as middle ear lymphatic fistula. Vestibular penetration is a seri-
effusion, fixation of prosthesis or ossicular rem- ous complication that represents 10% of stapes
nant by scar tympanosclerosis (especially involv- prosthesis complications. Signs of perilymphatic
ing the malleus or incus head in the epitympanum), fistula include the presence of air in the labyrinth
or recurrent cholesteatoma. Encasement of a (pneumolabyrinth) and rarely middle ear effusion.
prosthesis by granulation tissue or cholesteatoma The portion of the prosthesis at the stapes foot-
can cause conductive hearing loss whether or not plate can reliably penetrate the vestibule without
the ossicular prosthesis is displaced. causing symptoms is 0.25 mm, but slightly deeper
Complications of ossicular prostheses depend penetration may be asymptomatic in some cases.
on the particular type of prosthesis, but generally Prosthesis extrusion through the tympanic mem-
include migration into the vestibule (TORP or sta- brane occurs in 2.6–7% of cases depending on the
pes prosthesis) (Fig. 8.37), perilymphatic fistula type of prosthesis and method of tympanoplasty.
(Fig. 8.38), subluxation, dislocation, extrusion or The main risk factor for prosthesis extrusion is
other form of malposition (Figs. 8.39, 8.40, 8.41, ongoing Eustachian tube dysfunction. CT is the
8.42, 8.43, 8.44, 8.45, and 8.46), encasement/dis- modality of choice for evaluating most of these
placement by granulation tissue or recurrent cho- complications, especially in the late postoperative
lesteatoma (Figs. 8.47 and 8.48), tympanic period. However, MRI is generally better for char-
membrane dehiscence (Fig. 8.49), and bending or acterizing granulation tissue and cholesteatoma.
Fig. 8.37 Vestibular perforation. Coronal CT image

shows medial displacement of the stapes prosthesis into
the vestibule through the oval window
Fig. 8.38 Perilymphatic fistula. The patient presented

with acute vertigo after stapedectomy. Coronal CT image
shows air within the vestibule (arrow) and a laterally dis-
placed stapes prosthesis
Fig. 8.41 Stapes prosthesis detachment from the incus.

Coronal CT image shows an air gap (arrow) between the
lenticular process of the incus and McGee stapes
Fig. 8.39 Stapes prosthesis separation from the incus. prosthesis
Axial CT image shows an empty prosthesis wire loop
(arrow) adjacent to the incus (Courtesy of Mary Elizabeth
Cunnane, M.D.)
Fig. 8.42 Stapes bucket prosthesis dislocation. Axial CT

Fig. 8.40 Lateralized TORP. Coronal CT image shows an
image shows the distal end of the prosthesis (arrow) pro-
air gap (arrow) between the shaft of the hydroxyapatite
jecting far anterior to the region of the oval widow
prosthesis and the oval window. There is also extensive
nonspecific opacification of the widened external auditory
canal
Fig. 8.44 Dislocated PORP. Coronal CT image shows

the Wehr’s short single-notch incus prosthesis in the
hypotympanum, adjacent to the Eustachian tube orifice
Fig. 8.43 TORP facial nerve impingement. Coronal CT

image shows the medial ends of the prosthesis contacting
the tympanic segment of the facial nerve canal (arrow)
a b
Fig. 8.45 PORP detachment from stapes. Coronal (a) and axial (b) CT images show the shaft of the prosthesis sepa-
rated and angled away from the oval window, far removed from the stapes (arrow)
a b
Fig. 8.46 Extruded TORP. Axial (a) and coronal (b) CT images show the black oval-top prosthesis head that extends
lateral to the tympanic membrane, while the shaft still contacts the footplate
Fig. 8.48 Recurrent cholesteatoma with TORP displace-

ment. Axial CT image shows a cholesteatoma (*) that dis-
places the ossicular prosthesis
Fig. 8.47 Dislocated TORP encased in soft tissue. Poschl
plane CT image shows a hydroxyapatite TORP orientated
upside down and encased by nonspecific soft tissue
Fig. 8.49 Ossicular prosthesis tympanic membrane

Fig. 8.50 Prosthesis fracture. Axial CT image shows an
detachment. Coronal CT image shows separation of the
air gap (arrow) between the head and shaft of the
tympanic membrane graft (arrow) from the head of the
prosthesis
prosthesis
8.12 Atticotomy external auditory canal, or it may be part of a

more extensive combined approach that addition-
8.12.1 Discussion ally involves canal wall-up mastoidectomy. Canal
wall defects that result from atticotomy can eas-
Atticotomy, also known as epitympanectomy, ily be reconstructed with auricular cartilage or
consists of removing the bone of the lateral attic soft tissue grafts, but rarely these defects are
wall (scutum) in order to provide visualization of intentionally left open if the surgeon intends to
the attic contents and aditus ad antrum (Fig. 8.51). exteriorize part or all of the attic into the external
This procedure is most often used to treat attic auditory canal. Following atticotomy, CT or MRI
cholesteatoma or fixation of the ossicular heads. may be performed to evaluate for the presence of
Often, but not always, the body of the incus and recurrent cholesteatoma. Atticotomy is some-
head of the malleus are resected during atticot- times difficult to distinguish from autoatticotomy
omy if they are involved with disease or if wider where long-standing negative middle ear pres-
surgical exposure is needed. Atticotomy may be sure or cholesteatoma has generated an atticot-
applied as a stand-alone procedure through the omy defect.
Fig. 8.51 Atticotomy. Coronal CT image shows partial

absence of the left ossicles and surgical resection of the
scutum (encircled). The epitympanum is clear, but the
reconstructed tympanic membrane is atelectatic
8.13 E
ustachian Tube Occlusion as streaky or focal hyperattenuation on CT
Procedures (Fig. 8.53). The material can resorb over time.
Injected Teflon appears mildly hyperattenuating
8.13.1 Discussion on CT and sometimes incites a foreign body reac-
tion, which results in an encapsulated granuloma
A patulous Eustachian tube can cause autophony after 3–6 months following injection (Fig. 8.54).
and a sense of ear fullness. Intolerable symptoms Such lesions can also appear intensely hypermet-
can be treated via fat, Teflon, or hydroxyapatite abolic on PET. Other complications include inad-
injection into the Eustachian tube and surround- equate occlusion of the Eustachian tube and
ing soft tissues in order to create mass effect upon breakage or migration of the catheters and plugs,
an incompetent tubal valve. Alternatively, the which can lead to recurrent symptoms and
Eustachian tube can be occluded using Silastic impingement upon the ossicles (Figs. 8.55 and
tubes (Fig. 8.52). Injected hydroxyapatite appears 8.56).
Fig. 8.52 Eustachian tube catheter. Stenver plane CT

image shows the catheter (arrow) coursing through the
Eustachian tube
Fig. 8.53 Hydroxyapatite injection. Axial CT image
shows the high-attenuation focus of hydroxyapatite in the
left parapharyngeal soft tissues along the expected course
of the Eustachian tube (encircled)
Fig. 8.56 Displaced transtympanic Eustachian tube

Fig. 8.54 Teflon injection with granuloma formation. plug. Axial CT image shows the soft attenuation plug
Coronal CT image shows a hyperattenuating mass in the (arrow) within the mesotympanum, abutting the ossicular
left nasopharyngeal region. Biopsy confirmed the chain, rather than within the Eustachian tube orifice
presence of foreign body reaction. (Courtesy of Juan

Small MD)
Fig. 8.55 Eustachian tube catheter migration. Axial CT

image shows the catheter (arrow) impinging upon the
ossicles and tympanic membrane
8.14 M
astoidectomy and Mastoid tially maintained via tympanic membrane recon-
Obliteration struction (modified radical) (Figs. 8.57, 8.58,
8.59, 8.60, and 8.61). Sometimes, the surgeon
8.14.1 Discussion chooses to obliterate all or part of the mastoid
cavity or exteriorized attic with fascia, bone
There are two main types of mastoidectomy: chips, cartilage, or soft tissue rotational flaps in
canal wall-up mastoidectomy (also called intact order to reduce the postoperative risk of having a
canal wall mastoidectomy) in which the native high-maintenance chronically unstable canal
bony external auditory canal is preserved (except wall-down mastoid cavity (Figs. 8.62 and 8.63).
for perhaps a partial atticotomy defect) or canal Thin-section CT and MRI are the most useful
wall-down mastoidectomy in which the superior modalities for evaluating patients with potential
and posterior segments of the bony canal wall are complications following mastoidectomy. In par-
resected such that the mastoidectomy cavity and ticular, T2-weighted turbo spin echo and gradient
portions of the middle ear are thereby rendered echo sequences with multiplanar reformats are
exteriorized into the external auditory canal. best suited for evaluating the middle ear struc-
Canal wall-down mastoidectomy can be further tures, while high resolution T2-weighted steady
divided into radical and modified radical mas- state sequences are optimal for imaging the inner
toidectomy based on whether or not the entire ear. The use of T1-weighted sequences without
middle ear space is exteriorized with the ossicles and with contrast is recommended for an overall
removed (radical) or the middle ear space is par- assessment.
Fig. 8.57 Partial canal wall-up mastoidectomy. Axial CT

Fig. 8.58 Canal wall-up mastoidectomy. Axial CT image
image shows that the lateral cortex of the mastoid has
shows an intact posterior wall of the external auditory
been resected. The mastoid air cells are otherwise nearly
canal (EAC) and an air-filled mastoid bowl (*). Sometimes
intact. Sometimes a limited mastoidectomy such as this is
the mastoid cavity can lack aeration after canal wall-up
performed to drain a mastoid abscess
mastoidectomy if the lateral soft tissues scar inward to fill
the cavity
Fig 8.61 Modified radical mastoidectomy. Coronal CT

Fig. 8.59 Canal wall-down mastoidectomy. Axial CT image shows the repositioned right tympanic membrane
image shows resection of the posterior wall of the external margin overlying the horizontal semicircular canal and
auditory canal, such that the mastoid bowl (*) communi- resection of the mastoid air cells
cates with the external auditory canal
Fig. 8.60 Radical mastoidectomy. Axial CT image

shows the absence of the ossicles, but preservation of the Fig. 8.62 Mastoid obliteration with fat graft. Axial CT
facial nerve, which has been skeletonized (arrow) as it image shows fat graft present within the mastoidectomy
courses through the mastoid bowl bowl (*). Sometimes fat is used to obliterate a mastoid
cavity even if it is a canal wall-up procedure if a cerebro-
spinal fluid leak is present
Fig. 8.63 Mastoid obliteration with bone dust. Axial CT

image shows the bone dust (*) packing the mastoidec-
tomy bowl. The bone dust was harvested from the surface
of the mastoid cortex
8.15 Mastoidectomy is nonspecific, while MRI is well suited for eluci-

Complications dating the differential when there is soft tissue in
the postoperative cavity. Although both recurrent
8.15.1 Discussion cholesteatomas and granulation tissue are typically
hyperintense on T2-weighted and hypo-/isointense
Imaging after mastoidectomy may be performed to on T1-weighted MRI sequences, recurrent choleste-
evaluate for a variety of complications, including atomas tend to show rim enhancement, while post-
abscess formation surrounding the mastoidectomy operative granulation tissue fills in with contrast.
bowl, including intracranially (Fig. 8.64), chronic It is also important to distinguish recurrent cho-
infection of a canal wall-down mastoidectomy cav- lesteatomas from encephaloceles and cholesterol
ity, which may be associated with an unstable cav- granulomas. Residual cholesteatoma after surgical
ity and high facial ridge (Fig. 8.65), excess removal is most often found in the sinus tympani,
granulation tissue (Fig. 8.66), recurrent cholestea- the oval window niche, the anterior epitympanum,
toma, (Figs. 8.67 and 8.68), and facial nerve injury and the supratubal recess/protympanum, but can
(Fig. 8.69), which can lead to formation of repara- even be extratemporal. Residual cholesteatoma
tive neuromas (Fig. 8.70), cerebrospinal fluid leak- found within the mastoid itself, although possible,
age (Fig. 8.71), and encephaloceles (Fig. 8.72). is surprisingly uncommon except in extensive cases
Profound sensorineural hearing loss and vestibular or in cases that involve complex canal wall-down
weakness can also occur if the surgeon violates the mastoidectomy cavities. The main differential
labyrinth with the drill. diagnosis of recurrent cholesteatoma is postsurgi-
It is common for exteriorized mastoid cavities cal granulation tissue and encephalocele.
to become infected on a chronic or recurrent basis, Facial nerve injury is an uncommon complica-
and this may lead to the need for frequent office tion of tympanomastoidectomy. The tympanic
visits to clean debris, to treat granulation tissue, and and proximal mastoid segments of the facial
to apply antimicrobial medications. The stability of nerve are most likely to be involved. This may
a canal wall-down mastoidectomy cavity is highly result in a reparative granuloma. Nerve cable
dependent on surgical technique, and there are sev- grafts are sometimes used to repair the transected
eral factors notable on CT imaging that may be nerves. On CT, reparative neuromas appear as
implicated in cavity instability including a large bulbous enlargement of the nerve, and on MRI,
open mastoid tip filled with debris, a small or enhancement of the lesion can be appreciated.
absent meatoplasty, a high residual ridge of the Thus, the location and presence of enhancement
bone overlying the mastoid segment of the facial help differentiate post-mastoidectomy reparative
nerve (defined as 2 mm or greater proximal to the neuroma from recurrent cholesteatoma.
chorda tympani facial nerve junction), numerous If postoperative cerebrospinal fluid leak is sus-
residual diseased air cells, the absent or perforated pected, as discussed earlier, thin-section CT with
tympanic membrane, or residual cholesteatoma. multiplanar reformatted imaging is the first-line
Historically, recurrent cholesteatoma was imaging modality for evaluation. CT cisternography
encountered in one-third to one-half of patients is helpful when there are multiple defects. However,
treated with canal wall-up mastoidectomy and thin-section coronal double inversion recovery
roughly 10% of those treated with canal wall-down MRI is particularly useful for evaluating suspected
mastoidectomy. Due to the high failure rate of canal encephalocele after mastoidectomy, which usually
wall-up surgery, a planned second-look procedure results from tegmen dehiscence. This information
or planned radiologic imaging is usually part of the is important for guiding subsequent surgical repair.
treatment scheme. Imaging usually consists of CT Tegmen defects can be repaired using a variety of
or MRI with non-EPI diffusion-weighted imag- techniques, including fibrin glue, fascia grafts,
ing usually obtained 9–12 months after surgery. muscle graft, fat graft, bone graft, hydroxyapatite
Recurrent cholesteatomas tend to show restricted (Fig. 8.73), or a combination of these. Some of
diffusion, while granulation tissue does not. CT has these materials can resorb over time, predisposing
a high negative predictive value when it shows a to recurrent cerebrospinal fluid leak and/or
clear middle ear and mastoid cavity. However, CT encephalocele.
Fig. 8.65 Unstable mastoid cavity. Coronal CT image

shows opacification of the residual mastoid air cells and
Fig. 8.64 Coronal post-contrast T1-weighted MR image
debris along the margins of the mastoidectomy bowl
shows a peripherally enhancing lesion in the right tempo-
ral lobe (arrow) overlying the right canal mastoidectomy
bowl in a patient with a history of mastoiditis
a b
Fig. 8.66 Granulation tissue. Axial T2-weighted (a), T1-weighted (b), and post-contrast fat-suppressed T1-weighted
(c) MR images show enhancing soft tissue in the left mastoidectomy bowl (arrows)
Fig. 8.67 Recurrent cholesteatoma. Axial CT image (a)

shows globular opacification of the mastoidectomy bowl
(arrow)
a b
Fig. 8.68 Extratemporal cholesteatoma recurrence. The suppressed T1-weighted MRI (b), and ADC map (c) show
patient has a history of right mastoidectomy for cholestea- a cystic lesion in the right preauricular subcutaneous tis-
toma. Axial T2-weighted MRI (a), post-contrast fat- sues with restricted diffusion (arrows)
Fig. 8.69 Facial nerve dehiscence. The patient presented
with right facial nerve palsy after canal wall-down mas-
toidectomy. Axial CT image shows a defect in the bone
overlying the pyramidal turn of the facial nerve (arrow),
which is covered by skin graft
Fig. 8.70 Facial nerve injury with reparative

neuroma. Axial CT image shows enlargement of the a
tympanic segment of the facial nerve (arrow), which is
dehiscent following mastoidectomy and
tympanoplasty. Axial post-contrast T1-weighted MRI
(b) shows enhancement of the lesion (arrow)
b
b
Fig. 8.71 Cerebrospinal fluid leak after mastoidectomy.
The patient presented with otorrhea after transmastoid
biopsy. Axial image from a CT cisternogram with intra-
thecal injection of contrast demonstrates a small dehis-
cence in the tegmen tympani and contrast in the mastoid
defect (arrow)
Fig. 8.72 Encephalocele after mastoidectomy. Coronal

T2-weighted (a) and double inversion recovery (DIR)
T1-weighted (b) MR images show a defect in the tegmen
with extension of the brain and cerebrospinal fluid in the
mastoid bowl (arrows)
Fig. 8.73 Repair of tegmen defect with hydroxyapatite.

Coronal CT image shows a large defect in the tegmen follow-
ing canal wall-up mastoidectomy, which has been repaired
using hydroxyapatite (arrow) as well as temporal fascia
8.16 Temporal Bone Resection defects are also present. Subtotal temporal bone
resection involves extension of lateral temporal
8.16.1 Discussion bone resection margins to include the middle ear
and mastoid structures, the facial nerve, and the
Treatment of external auditory canal malignancies labyrinth. Total temporal bone resection involves
will often include temporal bone resection. Usually further extension of subtotal temporal bone resec-
these cases involve squamous cell carcinoma of the tion margins to include the sigmoid sinus/jugular
external ear, but sometimes parotid malignancies bulb and the intrapetrous carotid artery, but this
that secondarily extend into the ear and temporal radical procedure is almost never performed in the
bone. Temporal bone resection is typically classi- modern era. All types of temporal bone resection
fied as lateral, subtotal, or total (radical), some of may be extended to also include additional resec-
which are depicted in Figs. 8.74 and 8.75 and listed tion of adjacent involved structures, such as the
in Table 8.3. Lateral temporal bone resection mandibular condyle or dura. Parotidectomy and
involves en bloc removal of the tympanic mem- neck dissection are usually performed alongside
brane and entire external auditory canal and is temporal bone resection, and reconstruction may
appropriate for tumors limited to the external audi- involve primary closure with or without a skin
tory canal that have not penetrated the middle ear graft if the defect is small, but most often require a
or mastoid. As a consequence of lateral temporal myocutaneous flap. Imaging plays an important
bone resection, the temporomandibular joint is role in the postoperative follow-up for tumor recur-
rendered continuous with the tympanomastoid rence (Fig. 8.76). This may involve a combination
space, while mastoidectomy and auriculectomy of CT, MRI, and PET.
Fig. 8.74 Lateral
temporal bone resection.
Postoperative axial (a)
and coronal (b) CT
images demonstrate
essentially complete
resection of the tympanic
bone and ossicles. The
temporomandibular joint
is continuous with b
tympanomastoid defect.
The facial nerve is
preserved, but skeleton-
ized (arrows). The inner
ear structures are also
preserved. A radial
forearm free flap has been
packed into the surgical
cavity
a b
Fig. 8.75 Subtotal temporal bone resection. Axial CT weight was implanted. Axial (c) and coronal (d) temporal
head images (a, b) show left subtotal temporal bone resec- bone CT images show extensive resection of the temporal
tion with myocutaneous flap reconstruction. Labyrinth is bone structures, including the expected course of the
absent. Since the facial nerve was sacrificed, an eyelid facial nerve
Table 8.3 Types of temporal bone resection

a
Temporal
bone resection
type Description
Lateral Removal of the entire external auditory
canal and tympanic membrane
including attached malleus.
Intratemporal facial nerve and inner
ear are preserved
Subtotal Same as lateral temporal bone
resection with additional resection of
the facial nerve, all middle ear
structures, and inner ear. Great vessels
are preserved
Total Same as subtotal temporal bone
resection with additional resection of
the great vessels (sigmoid sinus/
jugular bulb and intrapetrous internal
carotid artery)
Fig. 8.76 Tumor recurrence after lateral temporal bone

resection. The patient has a history of squamous cell car-
cinoma. Axial CT image (a) shows subtle soft tissue atten-
uation in the resection cavity that extends into the
parapharyngeal space (arrows) and displaces the flap lat-
erally. The corresponding PET image (b) shows consider-
able hypermetabolic activity within the lesion (arrows),
which is now very conspicuous. There is normal activity
within the cerebellum
8.17 Cochlear Implants depending on the surgeon’s wishes based on the

length of the particular electrode array chosen
8.17.1 Discussion and the portion of the cochlea that one wishes to
stimulate. For routine cases, it is typical for the
Cochlear implants are electronic devices that can electrode to complete at least a 270 degree turn
provide the sense of sound to patients with severe within the cochlea, such that all the electrodes are
sensorineural hearing loss by direct stimulation seated within the cochlea. In patients with
of the cochlear nerve. Cochlear implants consist labyrinthitis ossificans, a cochleostomy with drill
of an external microphone, external speech pro- out of the ossified basal turn may be required
cessor, external transducer coil, internal receiver- (Fig. 8.79). A recess is sometimes drilled into the
stimulator, and electrode array within the cochlea. bone posterior to the mastoid cavity where the
The components, particularly the position of the body of the receiver-stimulator is to be set within
electrodes, are well seen on the modified Stenver a periosteal pocket in order to allow the device to
or Arcelin view (Fig. 8.77). The removable exter- sit flush along the surface of the skull.
nal component of a cochlear implant houses a Several imaging techniques have been used to
microphone, a speech microprocessor, and a depict cochlear implants, including conventional
radio-emitting coil that not only sends a signal to radiography, phase- contrast radiography, cone
the implanted receiver-stimulator but also powers beam CT, fusion of conventional radiographs
the device transcutaneously. The external coil is and CT images, and spiral CT. Most cochlear
held in place magnetically. The implanted implants are only compatible with MRI if the
receiver-stimulator contains a magnet, a com- internal magnet is removed through a minor pro-
puter chip, and an electrode array, which is surgi- cedure, but at some centers 1.5 T MRI images
cally threaded into the cochlea. The electrodes of have been safely obtained by tightly wrapping the
this array contain anywhere from 8 to 24 metallic head overlying the implant and closely observ-
leads that vary depending on the actual device in ing the patient during the scan. Alternatively, the
place. These electrodes are visible on CT as a electrodes can be left in position, while the rest
string of metallic beads. of the cochlear implant device is removed for the
Typical surgery for cochlear implantation con- MRI. The electrodes produce negligible artifacts
sists of performing a canal-wall-up mastoidec- on MRI at 1.5 T (Fig. 8.80). It is undesirable to
tomy and posterior tympanotomy drilled through remove the electrodes for prolonged periods of
the facial recess, which is defined as the space time because it can be difficult to reinsert the
between the facial nerve and the chorda tympani. device. Newer cochlear implants may be MRI
This allows visualization of the round window compatible without removing the internal mag-
niche where the electrode is introduced into the net, even up to 3 T; however, there can be artifact
scala tympani of the basal turn of the cochlea from the indwelling magnet that can limit the
either via the round window membrane itself or a usefulness of the MRI if obtained to view struc-
small cochleostomy drilled immediately adjacent tures of the head and neck. The specific model
to the round window (Fig. 8.78). The degree of MRI guidelines should nevertheless be verified
electrode extension into the cochlea will vary prior to scanning with MRI.
Fig. 8.77 Cochlear implant

a
components. Modified
Stenver (Arcelin) view (a)
shows the implanted antenna
and magnet (arrowhead) and
electronic components of the
receiver-stimulator (*), as
well as the electrode array
coiled within the cochlea
(arrow). Photograph of a
cochlear implant with an
enlarged view of the scalar
electrodes in the inset (b)
(Courtesy of Advanced
Bionics)
b
Fig. 8.78 Cochlear implant insertion through the round

window. Axial CT image shows that the electrode courses
through the mastoid bowl, across the facial recess, and b
into the cochlea via a widened round window (arrow)
Fig. 8.79 Cochlear implant insertion via cochlear drill

out. The patient had a diminutive basal turn of the cochlea.
Axial (a) and coronal (b) CT images show the electrode of
the cochlear implant passing through a drilled-out cochle-
ostomy rather than through the round window and hypo-
plastic basal turn. The mastoid has been obliterated for
perilymphatic fistula
Fig. 8.80 Cochlear implant electrodes on MRI. Axial DRIVE image shows the low signal intensity electrodes in
the right cochlea (arrow), with no significant artifacts. The subcutaneous magnet component of the implant was
removed for the scan
8.18 Cochlear Implant canal, coiling or buckling of the electrode array

Complications within the cochlea, incomplete insertion into the
cochlea, and “transcalar insertion” with violation
8.18.1 Discussion of the basilar membrane and osseous spiral lamina
such that the electrode extends from scala tympani
Complications related to cochlear implantation into scala vestibuli. Transcalar insertion will result
include infection, perilymphatic fistula from the in loss of any residual natural hearing by damag-
round window or cochleostomy site with pneumo- ing the delicate neurosensory elements and also
labyrinth, extrusion, erosion of the hardware into will result in postoperative new bone formation
the intracranial compartment, device malposition, that will require excessive high power settings/
and extrusion of the electrode out of the cochlea. battery requirements to overcome resulting high
(Figs. 8.81, 8.82, 8.83, 8.84, 8.85, 8.86, 8.87, 8.88, impedance. If a congenital cochlear anomaly is
and 8.89). Malposition of the electrode is a signifi- present, it is possible for the electrode array to
cant cause for cochlear implant malfunction and breach the deficient modiolus and extend into the
can be evaluated via dedicated radiographs or internal auditory canal. A defect in the otic cap-
temporal bone CT. Potential malpositions to con- sule can allow the electrodes to contact the laby-
sider include “false insertion” of the electrode into rinthine segment of the facial nerve, which can
hypotympanic air cells, Eustachian tube, or carotid result in unwanted stimulation of the facial nerve.
Fig. 8.82 Perilymphatic fistula. Axial CT image shows

pneumolabyrinth (arrow) following cochlear
implantation
Fig. 8.81 Receiver-stimulator hardware erosion into the
skull. Axial CT image shows a defect (arrow) in the squa-
mous temporal bone under the receiver-stimulator
hardware
Fig. 8.83 Electrode malpositioning. Coronal CT image Fig. 8.85 Incomplete cochlear implant electrode inser-
shows the “false insertion” of the electrode passing tion. Axial CT image shows the electrodes only partially
through hypotympanic air cells into the petrous apex and inserted into the basal turn of the cochlea due to obstruc-
clivus (arrow) tion by labyrinthitis ossificans (encircled)
Fig. 8.84 Lateral cochlear implant electrode malposi-

tioning. Axial CT image shows the distal end of the
cochlear implant coiled on itself within the vestibule
(arrow)
a b
Fig. 8.86 Cochlear implant malpositioning within the vestibule. Axial CT images at two different levels (a and b)
show that the electrodes enter the vestibule and lateral semicircular canal (arrows)
a b
Fig. 8.87 Cochlear implant electrode extrusion. Serial axial CT images (a–c) show that the cochlear implant is absent
from the cochlea and instead projects into the lumen of the external auditory canal (arrows)
a b
Fig. 8.88 Cochlear implant contact with facial nerve. Axial (a) and coronal (b) CT images show a defect in the otic
capsule with electrodes in contact with the labyrinthine segment of the facial nerve (arrows)
a b
Fig. 8.89 Transcalar electrode array insertion. Axial CT the basal turn (arrow), but winds up in the scala vestibuli
images at two different levels (a, b) show that the cochlear in the middle turn (arrowhead)
implant is properly positioned within the scala tympani in
8.19 Auditory Brainstem the lateral recess of the fourth ventricle adjacent
Stimulator to the lateral aspect of the cochlear nucleus via a
translabyrinthine or retrosigmoid approach
8.19.1 Discussion (Fig. 8.90).
Complications related to ABI insertion include
Auditory brainstem implants (ABIs) are used to suboptimal production of auditory stimuli, cere-
provide some form for hearing capacity when the brospinal fluid leak along the course of the wire,
contralateral ear provides no hearing or if there is and nonauditory stimuli, such as trigeminal neu-
concern of contralateral hearing loss, such as in ralgia. Thin-section CT may be used to evaluate
neurofibromatosis Type 2 patients. The compo- ABIs after implantation, although precise local-
nents of the ABI are analogous to cochlear ization can be limited by metallic streak artifacts.
implants and include a receiver-stimulator and Newer ABI models do not contain magnetic com-
electrode array. The electrodes are implanted via ponents and are MRI compatible.
a b
c d
Fig. 8.90 Auditory brainstem stimulator. The patient has (arrow) positioned in the left cerebellopontine angle.
a history of neurofibromatosis Type 2 and left-sided hear- T2-weighted spin echo (c) and GRE (d) MRI sequences
ing loss. Scout image (a) shows the receiver-stimulator also show the tip of the electrode (arrows) in the left cer-
and electrode tip (arrow) in the posterior fossa. Axial CT ebellopontine angle, which is more conspicuous on GRE
image (b) shows the auditory brain stimulator electrode due to blooming effects
8.20 R
epair of Perilymphatic fistula recurrence, which occurs in 8–47% of
Fistula cases. It is important to note that there may not be
an imaging correlate for recurrent perilymphatic
8.20.1 Discussion fistulas, although graft displacement can some-
times be observed. Temporal bone CT may be
Symptomatic perilymphatic fistulas can be useful to evaluate recurrent symptoms following
treated via surgical repair. Closure can be repair, whereby the presence of middle ear opaci-
obtained using packing materials such as tempo- fication beyond the round window niche may
ralis fascia, which appears as soft tissue attenua- indicate recurrent fistula.
tion on CT (Fig. 8.91). The main complication is
a b
Fig. 8.91 Repair of perilymphatic fistula. The patient has and coronal (b) CT images demonstrate temporalis fascia
a history of round window perilymphatic fistula repair, packing in the round window niche (arrows)
status post transcanal exploration and closure. Axial (a)
8.21 Endolymphatic Sac bone CT (Fig. 8.92). The surgery can be limited

Decompression to decompression alone, in which the endolym-
and Shunting phatic sac is not opened. Alternatively, the endo-
lymphatic sac can be incised and drained into
8.21.1 Discussion either the mastoid or subarachnoid space,
whereby a communication is created between the
Endolymphatic sac decompression and shunting sac and the basal cistern. Silicone shunt tubing or
have been used for treating intractable vertigo in valves can also be inserted and are sometimes
patients with Meniere’s disease. The procedure visible on temporal bone CT. It is also common
consists of performing mastoidectomy and to see the bone over the adjacent posterior semi-
exposing the plate of the bone overlying the sig- circular canal to be intentionally thinned, but
moid sinus and posterior cranial fossa dura. hopefully not violated, as a consequence of this
These changes are readily depicted on temporal surgery.
Fig. 8.92 Endolymphatic sac decompression. Axial CT

image shows a left mastoidectomy with a defect in the
region of the left vestibular aqueduct (encircled)
8.22 Labyrinthectomy (Fig. 8.93). On the other hand, the transcanal

approach involves simply opening the vestibule
8.22.1 Discussion so that the vestibular neurosensory elements can
be eliminated via the middle ear by elevating the
Labyrinthectomy is a treatment option for tympanic membrane and resecting a portion of
Meniere’s disease when preservation of hearing the scutum, as well as the stapes and incus. A
is not a consideration. The procedure can be per- defect between the round and oval windows is
formed via a transmastoid or transcanal approach. created (Fig. 8.94). No matter which approach is
The transmastoid approach consists of a canal used, vestibule defects are sometimes filled with
wall-up mastoidectomy removal of the semicir- Gelfoam or other packing material.
cular canals and ablation of the vestibule
a b
Fig. 8.93 Transmastoid labyrinthectomy. Axial (a) and coronal (b) CT images show an air-filled cavity (arrows) in the
expected location of the vestibule, which communicates with the mastoid bowl. The ossicles remain intact
Fig. 8.94 Transcanal labyrinthectomy. Axial (a) and

coronal (b) CT images show a defect that extends a
inferior to the oval window (arrow). There is also
disruption of the ossicular chain
b
8.23 Vestibular Nerve Section distal to the division between cochlear and ves-
tibular nerves. This procedure can be performed
8.23.1 Discussion via a retrosigmoid, retrolabyrinthine, or middle
cranial fossa approach, and changes associated
Vestibular nerve sectioning (neurotomy) is with these surgical approaches can be identified
another treatment option for intractable Meniere’s on radiologic images (Fig. 8.95). In particular,
disease if preservation of residual hearing is a thin-section steady state MRI sequences, can
consideration. Vestibular neurotomy consists of evaluate for residual vestibular nerve fibers that
delicately severing the vestibular nerve fibers just could be responsible for recurrent vertigo attacks.
a b
Fig. 8.95 Vestibular neurotomy. Sagittal CISS MRI auditory canal. Sagittal CISS of the normal contralateral
image (a) shows the absence of the vestibular and cochlear side (b) shows intact internal auditory canal nerves for
nerves in the internal auditory canal. The remaining sev- comparison
enth cranial nerve (arrow) sags posteriorly in the internal
8.24 S
uperior Semicircular Canal plish this include bone pate, fascia, and bone wax
Dehiscence Repair (plugging), bone graft, cartilage graft, and
hydroxyapatite cement (resurfacing and skull
8.24.1 Discussion base repair). It is very common that these patients
have diffuse thinning of the middle cranial fossa
Repair of superior semicircular canal dehiscence floor on both sides and sometimes cerebrospinal
is an option to treat associated vestibular and fluid leak or encephalocele may also be present.
audiological symptoms. The procedure can be On CT, bone graft, hydroxyapatite, and bone
performed via a transmastoid or middle cranial putty are high attenuation (Fig. 8.96), while tem-
fossa approach. Repair can be achieved via sev- poralis fascia and bone wax are generally imper-
eral techniques that aim to plug the dehiscent ceptible since they are used in small quantities
canal and/or resurface and repair the adjacent and have imaging characterization that blend in
middle cranial floor. Materials used to accom- with the surrounding soft tissues.
Fig. 8.96 Plugging of superior semicircular canal dehis-

cence. Coronal CT image demonstrates bone putty
(arrow) filling the defect along the lateral aspect of the
superior semicircular canal. The procedure was performed
via a transmastoid approach
8.25 T
ube Drainage of Petrous the cysts via the middle cranial fossa with drainage
Apex Cholesterol Granuloma into the sphenoid sinus via sphenoidotomy
(Fig. 8.97). The desired end result of treatment is
8.25.1 Discussion permanent ventilation of the cyst cavity (Fig. 8.98).
Potential complications of drainage include tube
Drainage tube insertion can be performed for obstruction with cyst recurrence and damage to the
treating symptomatic petrous apex cholesterol labyrinthine structures and surrounding cranial
cysts (granulomas). Silastic drainage tubes can be nerves, particularly the facial and trigeminal
inserted into the lesion after drilling of the tempo- nerves depending on the approach. Lesions that
ral bone and creating a drainage tract into the mid- are not amenable to tube drainage can be treated
dle ear. Alternatively, the tube can be inserted into by complete surgical resection.
a b
c d
Fig. 8.97 Transsphenoidal tube drainage of cholesterol Silastic drainage tube (arrows) that extends from the right
cyst. Axial (a) and coronal (b) CT images and axial petrous apex to the sphenoid sinus (Courtesy of Hugh
T2-weighted (c) and T1-weighted (d) MR images show a Curtin, M.D.)
a b
Fig. 8.98 Drained cholesterol cyst. Axial (a) and Stenver reformatted (b) CT images show an air-filled cavity in the
right petrous apex (*), which has demineralized walls
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Imaging of Orthognathic,
Maxillofacial, 9
and Temporomandibular
Joint Surgery
and Russell Reid
9.1 Vertical Ramus Osteotomy joint disc to recapture (Fig. 9.1). The procedure

yields satisfactory results and has fewer
9.1.1 Discussion complications than intra-articular techniques.

Expected changes following vertical ramus
Intraoral vertical ramus osteotomy is a treat- osteotomy that can be appreciated on imaging
ment option for mandibular prognathism. In this include cortical bone thickening, narrowing of
technique, a vertically oriented cut made in the the bone marrow space, medial tilting of the
mandibular ramus allows the mandibular ramus mandibular condyle, and masticator muscle
to be lengthened and the temporomandibular atrophy (Fig. 9.2).

Chicago, IL, USA
P.-L. A. Westesson, M.D., Ph.D., D.D.S.
R. Reid, M.D., Ph.D.
Department of Surgery, University of Chicago,
Chicago, IL, USA

DOI 10.1007/978-3-319-52341-5_9
Fig. 9.1 Vertical ramus osteotomy. The patient has a history of temporomandibular joint disc dysfunction. Panorex (a)
and lateral radiograph (b) show a unilateral left mandibular ramus vertical osteotomy (arrows)
Fig. 9.2 Muscle atrophy after vertical ramus osteotomy.

Axial CT image shows mildly decreased bulk of the
masticator muscles on the right (arrow), ipsilateral to
where vertical ramus osteotomy was performed
9 Imaging of Orthognathic, Maxillofacial, and Temporomandibular Joint Surgery 423
9.2 Sagittal Split Osteotomy (Fig. 9.3). Once repositioned, the mandible is inter-
nally fixed using either position screws or plates and
9.2.1 Discussion screws. Sagittal split osteotomies are sometimes
combined with other types of maxillofacial proce-
The sagittal split osteotomy is a commonly per- dures, such as the LeFort I osteotomy. Dysesthesia
formed procedure for correcting maxillofacial of the inferior alveolar nerve is one of the most
deformities, such as mandibular hypoplasia or common complications since the osteotomy is in
hyperplasia. The surgery consists of bilateral oste- the region of the inferior alveolar nerve. Facial
otomies through the mandibular ramus with either nerve palsy and maxillary nerve pseudoaneurysm
advancement or setback of the mandibular body are rare complications of the sagittal split surgery.
Fig. 9.3 Sagittal split

a b
osteotomy. The patient has a
history of maxillary
hypoplasia and transverse
discrepancy and mandibular
hyperplasia. Coronal (a) and
3D CT (b) images show an
osteotomy gap through the
mandibular angle (arrows)
and screw fixation
9.3 Genioplasty
9.3.1 Discussion
Genioplasty consists of altering the projection of

the genial tubercle of the mandible. It can be per-
formed via an osteotomy through the genial tuber-
cle and can generally be described as shortening or
lengthening genioplasty. The genial tubercle can
be repositioned in all three planes to correct the
sagittal, vertical, and transverse components of the
chin deformity by sliding the bone fragment
(Fig. 9.4). The osteotomy is performed well below
the dental roots and mental foramina in order to
avoid complications. Prostheses can be used for
lengthening genioplasty, such as those composed Fig. 9.5 Chin augmentation with implant. Coronal CT
of silicone, either alone or in conjunction with images show a silicone prosthesis (arrow) positioned
advancement osteotomy (Figs. 9.5 and 9.6). anterior to the genial tubercle
Fig. 9.6 Lengthening genioplasty with combined osteot-

omy and implant. The patient has a history of Nager’s
Fig. 9.4 Sliding genioplasty. 3D CT image shows ante- syndrome with severe micrognathia. Sagittal CT image
rior translation of the inferior portion of the mandibular shows the low attenuation porous polyethylene implant
body, producing a step-off (arrow) (arrow) and the advanced genial tubercle with fixation
hardware
9.4 Mandibular Angle most commonly used materials for augmenta-

Augmentation tion include silicone and porous polyethylene.
The goal is to improve facial contours while
9.4.1 Discussion maintaining the pterygomasseteric sling. Cross-
sectional imaging can be useful for evaluating
Mandibular angle augmentation with alloplastic the position of the implants and assessing for
implants is an option for correcting hemifacial complications, such as foreign body granulomas
microsomia and other deformities (Fig. 9.7). The and infection.
a b
Fig. 9.7 Mandibular angle augmentation. The patient has (a) and contrast-enhanced T1-weighted (b) MR images
a history of hypoplastic right mandible in a patient with show that the implant material has intermediate T2 and
hemifacial microsomia. The implant has a density inter- low T1 signal (arrows)
mediate between fat and fluid. The coronal T2-weighted
9.5 Mandibular Distraction titanium and are therefore radiopaque and can be
adjusted from the exterior. The devices are attached
9.5.1 Discussion to the mandible after mandibular osteotomy has
been performed. The goal of this technique is
Mandibular distraction devices are used for man- to promote gradual bone growth (osteogenesis)
dibular bone lengthening to treat both posttrau- across the gap created by the corticotomy and
matic deformities and congenital mandibular distraction. Bone growth, alignment, and most
deficiencies. The devices are available as single complications can be evaluated via radiographs
(Fig. 9.8) versus multivector/curvilinear (Fig. 9.9) or CT. Complications of mandibular distraction
and internal versus external designs. In addition, osteogenesis include relapse, tooth injury, hyper-
transport distractors can be used to shift bone frag- trophic scarring, nerve injury, infection, inappro-
ments anteriorly or posteriorly (Fig. 9.10). The priate distraction vector, device failure, fusion
devices are usually composed of stainless steel or error, and temporomandibular joint injury.
a b
Fig. 9.8 Single-vector distraction device. The child has a right mandibular device in position, which spans the
history of congenital right mandibular deficiency. Scout osteotomy gap in the mandibular ramus
(a) and 3D CT (b) images demonstrate a single-vector
Fig. 9.9 Curvilinear
a b
distraction device. Sagittal CT
images (a, b) obtained at
different time points show
interval inferior advancement
of the lower foot of the device
Fig. 9.10 Transport distraction device. The patient has

extensive facial fractures secondary to a gunshot wound.
3D CT image shows the transport distractor device
(arrow) positioned across the left mandibular body defect
with satisfactory vector alignment
9.6 LeFort I Osteotomy applied adjacent to the osteotomy site in order to

promote healing. Diagnostic imaging may be used
9.6.1 Discussion to assess postoperative alignment, for which high-
resolution CT with 3D reformats is particularly
The LeFort I osteotomy procedure and its modifi- insightful (Fig. 9.11). Anatomical complications
cations are commonly performed to correct mal- occur in 2 to 3% of cases and include deviation
occlusion and maxillomandibular deformities. of the nasal septum, nonunion of the osteotomy
LeFort I osteotomies and modifications thereof are gap, and impingement upon the nasolacrimal duct
performed in conjunction with other procedures, (Fig. 9.12), while significant infections, such as
such as sagittal split osteotomies and approaches abscesses or maxillary sinusitis, occur in approxi-
to the skull base via a transoral route. The stan- mately 1% of cases. Furthermore, perforation of
dard procedure involves separating and moving the periosteum in the maxillary sinuses can lead
forward the anterolateral walls of the maxillary to herniation of the buccal fat pad, which may
sinus, inferior portion of the nasal cavity, and pter- not only obscure the surgical field but can lead
ygoid plates. Fixation of the osteotomy fragments to sinus obstruction (Fig. 9.13). Neurovascular
can be accomplished using microfixation plates injury involving the palatine canal can occur with
and screws. Alternatively, maxillary distractors pterygomaxillary disjunction when the osteotomy
can be used to gradually correct the deformity as extends too far posteriorly beyond the piriform
osteogenesis progresses. Bone grafts can also be rim (Fig. 9.14).
a b
Fig. 9.11 LeFort I osteotomy with microfixation plate. secured with plates and screws, resulting in improved
Preoperative 3D CT image (a) shows maxillary underjet dental occlusion. Bilateral sagittal split osteotomies were
associated with midface hypoplasia. Postoperative 3D CT also performed
images (b and c) show bilateral LeFort I osteotomies
Fig. 9.12 Nasolacrimal duct obstruction following Fig. 9.14 Palatine canal disruption. Axial CT image
LeFort I osteotomy with internal fixation. Axial CT shows the LeFort osteotomy traversing the right greater
images show a bone fragment (arrow) displaced into the palatine canal (arrow)
right nasolacrimal duct by the adjacent screw
Fig. 9.13 LeFort I surgery with buccal fat herniation into

the maxillary sinus. Axial CT image shows portions of
buccal fat within the bilateral maxillary sinuses
9.7 LeFort III Osteotomy complications particular to LeFort III proce-

dures include cerebrospinal fluid rhinorrhea,
9.7.1 Discussion meningitis, and ocular and cerebral injury.
The LeFort III procedure is indicated for cor-

recting midface hypoplasia involving the nasal
and zygomatic complex and orbits, such as
with Crouzon, Apert, and Pfeiffer syndromes.
Indeed, LeFort III advancement can augment
the orbital volume and surface area with correc-
tion of the ocular bulb proptosis in addition to
correcting malocclusion. While variations exist,
the LeFort III procedure essentially involves
performing osteotomies through the frontozy-
gomatic suture, floor of the orbit, and the nasion
and separating the vomer and ethmoid from
the cranial base in the midline and the ptery-
gomaxillary junction. Mobilization of the mid-
face is an extensive procedure, with a high risk
of blood loss. In order to minimize morbidity,
gradual advancement via distraction osteogen-
esis can be performed (Fig. 9.15). Once again,
high-resolution craniofacial CT with 3D recon-
structions can be used to assess the degree of
anatomic changes after surgical treatment and
Fig. 9.15 LeFort III osteotomy with distraction osteo-
evaluate certain complications. In addition to genesis. Postoperative 3D CT image shows bilateral trans-
some of the complications that may be encoun- orbital and zygomatic osteotomies with distraction
tered with LeFort I osteotomy and distraction, devices in position
9.8 ixation of Mandible

F bars or their derivatives to the mandible and max-
Fractures illa, confirming appropriate reduction, and apply-
ing fixation wires.
9.8.1 Discussion Complications that may result from mandible
fracture fixation include malunion/nonunion,
A variety of techniques can be used to treat man- hardware failure, and osteomyelitis. Imaging
dible fractures, including maxillomandibular fix- plays a role in evaluating these complications and
ation (Figs. 9.16 and 9.17), open reduction and planning a secondary operation. The panorex and
internal fixation using plates and screws with or 3D CT images are particularly useful for provid-
without maxillomandibular fixation (Fig. 9.18), ing a complete view of the hardware and fractures.
and external fixation device application (Fig. Most of the hardware fixation components are
9.19). Maxillomandibular fixation consists of metallic, although sometimes stiff rubber bands
applying circumdental wires, securing Erich arch are used to secure the maxilla to the mandible
Fig. 9.17 Maxillomandibular fixation with intermaxil-

lary fixation (IMF) screws and wire. 3D CT shows the
screws securing the wire in a figure of eight configuration
Fig. 9.16 Maxillomandibular fixation with Erich arch

bars. Panorex (a) shows bilateral mandibular fractures
(encircled) and the metallic maxillomandibular fixation
hardware at the level of the maxilla. Clinical photograph
of maxillomandibular fixation with rubber bands (b)
(Courtesy of Patrik Keshishian, DDS)
9.9 Mandibulotomy
9.9.1 Discussion
The transcervical and transcervical-parotid

approaches are routinely performed to resect
tumors of the parapharyngeal space. Occasionally,
the wider exposure necessary for large or malig-
nant tumors can be provided by midline or para-
symphyseal mandibulotomy (Fig. 9.20). An
additional mandibular ramus osteotomy, or “dou-
ble osteotomy,” can be performed if additional
exposure is required. These maneuvers allow for
complete tumor resection without significant dis-
ruption of dentition, sensation, or occlusion.
Fig. 9.18 Open reduction and internal fixation and max-

illomandibular fixation. 3D CT image shows plate and
screw fixation of a mandible body fracture. Bilateral
displaced subcondylar fractures are also present without
hardware fixation
Fig. 9.20 Parasymphyseal mandibulotomy. The patient

is status post tongue base carcinoma resection.
Mandibulotomy was performed to gain access to the
lesion. Coronal CT image shows a parasagittal defect in
the body of the mandible (arrow), which is otherwise
fixed via metal plate and screws
Fig. 9.19 External fixation of comminuted mandible

fractures. Frontal radiographic image shows the external
fixation device in position. Numerous other facial frac-
tures treated via internal fixation and scattered metallic
debris are also noted, which represent bullet fragments
from a self-inflicted gunshot wound
9.10 Enucleation taneous filling of the residual cavities have

been reported to occur in all cases of uncom-
9.10.1 Discussion plicated mandibular cyst enucleation. In par-
ticular, the cavities generally decrease in size
Enucleation of tumors and cysts can produce by over 80% by 24 months. Similarly, bone
irregular margins and periosteal reaction that density increases by over 90% by 24 months
appears aggressive and can resemble infection on average. Complications of these procedures
of tumor recurrence/progression (Fig. 9.21). include tumor recurrence or seeding, injury to
Sometimes the cavities are filled with bone the inferior alveolar nerve, osteomyelitis, and
graft material. Nevertheless, healing and spon- soft tissue infections.
a b
Fig. 9.21 Enucleation. The patient has a history of brown andibular body (arrow). Sagittal CT obtained 3 months
m
tumor of the mandible. Sagittal CT image obtained later (b) demonstrates interval healing of the defect (arrow)
3 weeks enucleation (a) shows a defect in the right
9.11 Cyst Decompression 6–8 months, at which point the cysts decrease

in size on average by 80%. The procedure con-
9.11.1 Discussion sists of unroofing the cyst, irrigating the cyst
cavity. The stents are inserted in the cavity and
Decompression with stenting can be used to secured by the overlying mucosa and sutures.
treat large mandibular cysts (Fig. 9.22). The The stent appears as a high-attenuation tubular
stents typically remain in position for about structure on CT.
a b
Fig. 9.22 Cyst drainage. Panoramic radiograph (a) in a Axial image (b) in a different patient with a history of
patient with a right mandibular angle dentigerous cyst odontogenic keratocyst shows a stent (arrow) within a
treated with fenestration and stent decompression (arrow). right mandibular cyst cavity
9.12 Coronoidectomy mies across the base of the coronoid process but
often leaving at least some portion of the coro-
9.12.1 Discussion noid process behind (Fig. 9.23). Alternatively,
transzygomatic coronoidectomy performed for
Excessively elongated coronoid processes of the zygomaticocoronoid ankyloses or pseudoarthro-
mandible can result in trismus. Treatment con- sis typically involves resection of the abnormal
sists of coronoidectomy, which can be performed section of the zygomatic arch and coronoid pro-
endoscopically, and involves performing osteoto- cess (Fig 9.24).
a b
Fig. 9.23 Endoscopic coronoidectomy. The patient had a abnormally elongated coronoid process. Postoperative
history of Hecht syndrome (trismus-pseudocamptodactyly sagittal CT image (b) shows interval fragmentation of the
syndrome). Preoperative sagittal CT image (a) shows an coronoid process
a b
c d
Fig. 9.24 Transzygomatic coronoidectomy. The patient zygomaticocoronoid ankylosis (arrow). The postoperative
has a history of arthrogryposis multiplex congenita. The axial (c) and 3D (d) CT images show interval resection of
preoperative axial (a) and 3D (b) CT images show left the fused zygomaticocoronoid segment
9.13 Mandibulectomy bone segments. Condylectomy consists of resect-

and Mandibular ing the mandibular condyle, often along with the
Reconstruction disc and joint capsule (Figs. 9.27 and 9.28). This
procedure may be performed for resection of
9.13.1 Discussion lesions that affect the temporomandibular joint
such as pigmented villonodular synovitis or neo-
Various types of mandibulectomy can be per- plasm of the mandible that extends to the condyle.
formed for treating both developmental and neo- Occasionally, transport distractors for osteogen-
plastic conditions. Marginal mandibulectomy esis are used in the reconstruction. Complications
consists of excising part of the surface of the related to mandibulectomy and condylectomy
mandible, usually the inner surface, and is mainly include infection (Fig. 9.29), devasculariza-
performed to minimal tumor extension into the tion/osteonecrosis (Fig. 9.30), hardware failure
mandible (Fig. 9.25). Segmental mandibulec- (Fig. 9.31), dislocation/malocclusion that is often
tomy consists of resecting the full thickness of accompanied by accelerated degenerative disease
a portion of the mandible, leaving a gap between of the temporomandibular joints secondary to the
segments of the mandible (Fig. 9.26). The mandi- altered biomechanical stresses (Fig. 9.32), and
ble is often reconstructed using a variety of grafts, tumor recurrence, which is often best depicted on
such as a free fibula osteocutaneous flap. Plates MRI (Fig. 9.33).
and screws are also incorporated for securing the
Fig. 9.25 Marginal mandibulectomy. Sagittal CT image

shows right marginal mandibulectomy of right mandibu-
lar body following ameloblastoma resection several years
before. The edges of the osteotomy have healed
Fig. 9.26 Segmental mandibulectomy. 3D CT image

demonstrates resection of a large portion of the right man-
dible with fibula bone graft and sideplate and screw
reconstruction
Fig. 9.27 Condylectomy. The 3D CT image demon-

strates the absence of the right mandibular condyle leav- Fig. 9.29 Graft infection. Sagittal CT image shows gas
ing a gap between the healed mandibular ramus osteotomy and fluid collections (arrows) in the surgical bed
and glenoid (encircled)
Fig. 9.30 Devitalized fibular graft. Coronal CT image

shows demineralization of the right mandibular fibular
bone graft (arrow)
Fig. 9.28 Partial mandibulectomy and condylectomy
with condylar prosthesis. 3D CT shows a left mandibular
body and condyle prosthesis. There is also a custom bipo-
lar transport distractor (arrow)
a b
Fig. 9.31 Hardware fracture. Axial CT image (a) (encircled). Axial CT image in a different patient (b)
obtained after partial mandibulectomy and sideplate and shows overlap of the fractured mandibular reconstruction
screw reconstruction shows a displaced fracture of a screw plate
Fig. 9.32 Temporomandibular joint dislocation and

accelerated arthritis. Axial CT image obtained after right
partial mandibulectomy shows anterior dislocation of the
right condyle due to the unopposed forces of the pterygoid
muscles after surgery. There is also secondary degenera-
tive change affecting the left temporomandibular joint
related to the altered biomechanics
Fig. 9.33 Tumor recurrence. The patient has a history of
ameloblastoma treated via left hemimandibulectomy.
Coronal fat-suppressed post-contrast T1-weighted MRI
shows a heterogeneous mass in the region of the left gle-
noid fossa with intracranial extension
9.14 E
minectomy and Meniscal the articular eminence of the glenoid (Fig. 9.34).
Plication For plication, the lateral pterygoid is detached
from the meniscus, which is then rotated such
9.14.1 Discussion that the disc from the posterior portion overlies
the condylar head as a cap upon the condyle.
Eminectomy with or without meniscal plication Anchors can be placed to ensure stability of the
is a treatment option of chronic, recurrent tem- construct. On MRI, the absence of the eminence
poromandibular joint dislocation. The recurrent and a thickened disc are apparent. In addition,
dislocations often result in pterygoid spasm and MRI can show increased rotation and translation
severe pain. Eminectomy consists of resecting of the condylar head.
a b
Fig. 9.34 Eminectomy. Both patients have a history of nence with anterior translation of the condyle to remain in
chronic left temporomandibular joint dislocation treated the appropriate range of motion. Sagittal proton density
via eminectomy, temporomandibular joint meniscus pli- MRI in another patient (b) shows thickening of the folded
cation, and lateral pterygoid myotomy. Sagittal CT (a) disc (arrow) and flattening of the articular eminence
image shows reduction and flattening of the articular emi-
9.15 Temporomandibular Joint poromandibular joint discectomy, a narrow soft

Discectomy tissue interface normally forms between the man-
dibular condyle and the glenoid fossa, which
9.15.1 Discussion effectively functions as a substitute for the
resected disc. On MRI, this soft tissue has inter-
Discectomy without disc replacement has been mediate to high signal intensity (Fig. 9.35). The
used as a treatment for painful temporomandibu- soft tissue normally mineralizes over time, result-
lar joint internal derangement. Following tem- ing in a shallower glenoid fossa.
a b
Fig. 9.35 Discectomy. The patient has a history of tem- to high signal in the joint space. The contralateral sagittal
poromandibular joint cyst treated via discectomy. proton density MRI (b) shows the normal disc (arrow) for
Postoperative sagittal proton density MRI (a) shows the comparison
absence of the low-signal disc and an area of intermediate
9.16 Temporomandibular Joint resecting the mandibular condyle, trimming the

Costochondral Graft cartilaginous portion of the graft to match the nor-
Reconstruction mal contour of the articular surface, and affixing
the osseous portion of the graft to the mandibu-
9.16.1 Discussion lar ramus (Fig. 9.36). This type of reconstruction
provides satisfactory function in the majority of
The morphology and tissue components make cases. However, complications include fracture,
rib costochondral grafts well suited for temporo- continued ankylosis, differential growth of the
mandibular joint reconstruction, particularly in graft with respect to the contralateral side, degen-
the pediatric population due to the graft’s growth erative disease (Fig. 9.37), and graft resorption
potential. The procedure generally consists of (Fig. 9.38).
Fig. 9.36 Rib grafts. The

a b
patient has a history of
hemifacial microsomia, status
post costochondral
reconstruction of the right
temporomandibular joint.
Coronal (a) and 3D (b) CT
images show the cartilaginous
portion of the right
costochondral graft seated
within the glenoid fossa. The
osseous portion of the graft is
attached to the mandibular
ramus by plate and screw
fixation
Fig. 9.38 Rib graft resorption. Coronal CT image dem-

onstrates small inferior remnants of the bilateral rib grafts
resulting in superior migration of the mandible and ero-
sion of the fixation hardware into the zygomatic processes
Fig. 9.37 Rib graft degenerative disease. Sagittal CT

image shows joint space narrowing between the left rib
graft and the zygomatic arch (encircled) due to severe
thinning of the cartilage
9.17 Temporomandibular Joint implants were intended to be permanent, but have

Disc Replacement Implants been banned by the FDA. Silicone implants can
be used either on a temporary or a permanent
9.17.1 Discussion basis. Both types of implants appear as uniformly
low-signal, linear structures on both T1-weighted
Two main types of alloplastic temporomandibu- and T2-weighted MRI sequences. On CT, both
lar joint disc implants have been used: Proplast- types of prostheses are hyperattenuating
Teflon and silicone rubber (Silastic). Proplast (Fig. 9.39).
Fig. 9.39 Silastic implant. Coronal CT image shows the

implant is well-seated in the temporomandibular joint
space (arrow)
9.18 Temporomandibular Joint ramus-condyle (Figs. 9.41 and 9.42), which

Hemiarthroplasty directly contacts the opposing articular surface.
Sometimes a fat graft is also applied adjacent to
9.18.1 Discussion the prosthesis. Revision surgery is ultimately
required in over 20% of cases without fat graft
Hemiarthroplasty consists of resurfacing one and about 6% of cases with fat graft.
side of the temporomandibular joint with either
prosthesis for the fossa-eminence (Fig. 9.40) or
Fig. 9.40 Temporomandibular joint hemiarthroplasty

glenoid implant. Sagittal CT image shows a metallic
implant seated in the glenoid fossa (arrow) (Courtesy of
Joel Curé, MD) Fig. 9.42 Lorenz prosthesis. Lateral radiographs shows
right mandibular ramus osteotomy and a prosthesis that
includes a metallic condylar component and a radiolucent
glenoid fossa component (encircled), both of which are
secured via titanium screws
Fig. 9.41 Temporomandibular joint hemiarthroplasty

with ramus-condyle unit implant. Frontal scout image
shows bilateral ramus-condyle hardware
9.19 Temporomandibular Total

Joint Arthroplasty
9.19.1 Discussion
Total temporomandibular joint resurfacing

is performed in order to restore normal jaw
motion and provide pain relief for a variety of
conditions, such as neoplasms, arthritis, and
ankylosis. The main types of temporomandibu-
lar prostheses include fossa-eminence, condy-
lar, and total temporomandibular replacement.
Although success rates of at least 90% have
been achieved with some designs and materials,
proper fitting of the prosthetic components to
the skull is challenging. As a result, presurgi-
cal CT is often used to customize TMJ prosthe-
ses, thereby optimizing stability and function.
The implants usually consist of radiopaque
metallic condylar component and either radio-
lucent polymer components (plastic-on-metal)
(Fig. 9.43) or metallic glenoid fossa components
Fig. 9.43 Synthes total joint prosthesis. 3D CT image shows
(metal-on-metal) (Fig. 9.44). In addition, three both metallic mandibular and glenoid fossa components
component prostheses have been introduced,
such as the Concepts total temporomandibular
joint prosthesis, which includes a plastic spacer
positioned between the glenoid and condylar
implants (Fig. 9.45).
a b
Fig. 9.44 TMJ Concepts

total joint prosthesis. Frontal
(a) radiograph shows a
radiolucent gap between the
metallic glenoid and condylar
prosthesis components.
Sagittal CT image (b) shows
the radiolucent component
(arrow), which is well-seated
between the metallic condylar
and glenoid fossa implants
9.20 Temporomandibular Joint accurately delineates migration and fragmenta-

Disc Implant and Prosthesis tion of the hyperattenuating Proplast- Teflon
Failure implant, soft tissue calcifications, and destruc-
tive changes of the adjacent osseous structures.
9.20.1 Discussion MRI is well suited for depicting the soft tissue
changes, including the intermediate T1 and T2
Proplast-Teflon laminate implants were first used signal-enhancing foreign body granuloma and the
in temporomandibular joint meniscectomy (inter- presence of associated avascular necrosis in the
positional arthroplasty) for treatment of internal surrounding bone, which can appear as decreased
derangement in 1974 and became available as marrow signal on T1. Ultimately, erosive change
precut discs in 1983. However, Proplast-Teflon of the glenoid fossa and the mandibular condyle
implants were prone to perforation, fragmenta- can result. The integrity of the glenoid fossa is
tion, migration, and foreign body reaction, which critical since erosions can extend into the middle
can lead to severe condylar, glenoid fossa, and cranial fossa (Fig. 9.47). Osteolysis with loos-
articular eminence erosion, as well as penetration ening of temporomandibular joint prostheses is
into the middle cranial fossa (Figs. 9.45 and 9.46). another complication that can be associated with
Patients may present even after many years with pain and is recognized by the presence of lucency
temporomandibular joint pain, decreased joint between the bone and the prosthesis that mea-
range of motion, crepitus, preauricular swelling, sures greater than 2 mm (Fig. 9.48). Loosening
regional lymphadenopathy, malocclusion, and can be accompanied by dislocation of the pros-
facial deformity, often requiring implant removal thesis. Alternatively, new bone formation can
and debridement of the joint. The degree of result in ankylosis and limitation of mouth open-
facial pain correlates with perforation and breaking. Pseudoarthroses can sometimes form in the
down of the implants. Due to their high failure bony mass and can appear as linear lucencies on
rate, Proplast-Teflon temporomandibular joint CT (Fig. 9.49). Evaluation of temporomandibular
implants were removed from the market in 1993. joint prosthetic complications often requires both
Failed Proplast-Teflon temporomandibular joint MRI and CT. MRI readily shows the extent of
implants often result in bony erosions, which infection, fragmentation of the implant material,
could be poorly or well defined, with or without and distension of the joint capsule, while CT is
sclerotic margins. CT can reveal soft tissue mass useful for evaluating the integrity of the implants
corresponding to foreign body granuloma and and associated osseous structures.
a b
Fig. 9.45 Teflon granuloma. Axial CT image (a) shows density MR image in a different patient (b) shows an
the linear hyperattenuating implant in the temporoman- expanded joint capsule and intermediate-signal-intensity
dibular joint space. The glenoid fossa is markedly material surrounding the low-signal-intensity implant
expanded secondary to a soft tissue mass. Sagittal proton (arrow)
Fig. 9.46 Implant perforation. Sagittal CT image shows

a fragmented silicone implant (arrow)
Fig. 9.47 Implant intracranial migration. Coronal sagit-

tal CT image shows erosion of the Teflon portion of the
implant into the middle cranial fossa (arrow)
a b
Fig. 9.48 Temporomandibular joint prosthesis dislocation. Coronal (a) and 3D (b) CT images show inferomedial dis-
location of the left condylar prosthesis from the radiolucent component (arrow)
Fig. 9.49 Pseudoarthrosis. Coronal CT image shows

superolateral migration of the right temporomandibular
joint hemiarthroplasty hardware. The lucency (arrow)
between the medial mandibular ramus and the skull base
represents a pseudoarthrosis
Further Reading Semergidis TG, Migliore SA, Sotereanos GC (1996)

Alloplastic augmentation of the mandibular angle.
J Oral Maxillofac Surg 54(12):1417–1423
Vertical Ramus Osteotomy
Chen CM, Lee HE, Yang CF, Shen YS, Huang IY, Tseng
YC, Lai ST (2008) Intraoral vertical ramus osteotomy Mandibular Distraction
for correction of mandibular prognathism: long-term
stability. Ann Plast Surg 61(1):52–55 Chopra S, Enepekides DJ (2007) The role of distraction
Jung YS, Kim SY, Park SY, Choi YD, Park HS (2010) osteogenesis in mandibular reconstruction. Curr Opin
Changes of transverse mandibular width after intraoral Otolaryngol Head Neck Surg 15(4):197–201
vertical ramus osteotomy. Oral Surg Oral Med Oral Goiato MC, Ribeiro AB, Dreifus Marinho ML (2009)
Pathol Oral Radiol Endod 110(1):25–31 Surgical and prosthetic rehabilitation of patients
Westesson PL, Dahlberg G, Hansson LG, Eriksson L, with hemimandibular defect. J Craniofac Surg
Ketonen L (1991) Osseous and muscular changes 20(6):2163–2167
after vertical ramus osteotomy. A magnetic reso- Master DL, Hanson PR, Gosain AK (2010) Complications
nance imaging study. Oral Surg Oral Med Oral Pathol of mandibular distraction osteogenesis. J Craniofac
72(2):139–145 Surg 21(5):1565–1570
Sagittal Split Osteotomy Lefort I Surgery
Patel PK, Novia MV (2007) The surgical tools: the Buchanan EP, Hyman CH. LeFort I Osteotomy. Semin
LeFort I, bilateral sagittal split osteotomy of the man- Plast Surg 2013:27(3):149–154.
dible, and the osseous genioplasty. Clin Plast Surg Kramer FJ, Baethge C, Swennen G, Teltzrow T, Schulze
34(3):447–475 A, Berten J, Brachvogel P. Intra- and perioperative
Rai KK, Shivakumar HR, Sonar MD (2008) Transient complications of the LeFort I osteotomy: a prospec-
facial nerve palsy following bilateral sagittal split tive evaluation of 1000 patients. J Craniofac Surg
ramus osteotomy for setback of the mandible: a review 2004;15(6):971-977; discussion 978–9.
of incidence and management. J Oral Maxillofac Surg Li KK, Meara JG, Alexander A Jr. Location of the
66(2):373–378 descending palatine artery in relation to the Le Fort
Silva AC, O’Ryan F, Beckley ML, Young HY, Poor D I osteotomy. J Oral Maxillofac Surg 1996;54(7):822–
(2007) Pseudoaneurysm of a branch of the maxil- 825; discussion 826–7.
lary artery following mandibular sagittal split ramus
osteotomy: case report and review of the literature.
J Oral Maxillofac Surg 65(9):1807–1816
Lefort III Surgery
Festa F, Pagnoni M, Valerio R, Rodolfino D, Saccucci M,

Genioplasty d’Attilio M, Caputi S, Iannetti G. Orbital volume and
surface after Le Fort III advancement in syndromic cra-
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Radiology 219(2):334–345 Nout E, Cesteleyn LL, van der Wal KG, van Adrichem
Lindquist CC, Obeid G (1988) Complications of genio- LN, Mathijssen IM, Wolvius EB. Advancement of
plasty done alone or in combination with sagittal split- the midface, from conventional Le Fort III osteotomy
ramus osteotomy. Oral Surg Oral Med Oral Pathol to Le Fort III distraction: review of the literature. Int
66(1):13–16 J Oral Maxillofac Surg 2008;37(9):781–789.
Patel PK, Novia MV (2007) The surgical tools: the
LeFort I, bilateral sagittal split osteotomy of the man-
dible, and the osseous genioplasty. Clin Plast Surg
34(3):447–475 Fixation of Mandible Fractures
Choi BH, Huh JY, Yoo JH (2003) Computed tomographic

findings of the fractured mandibular condyle after open
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Bastidas N, Zide BM (2010) The treachery of mandibular two-miniplate fixation and complications. Arch Facial
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Gear AJ, Apasova E, Schmitz JP, Schubert W (2005) Ramalho-Ferreira G, Faverani LP, Fabris AL, Pastori
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Yamamoto MK, D’Avila RP, de Cerqueira Luz JG (2013) ration through bilateral coronoidectomy by intraoral
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Chana JS, Chang YM, Wei FC, Shen YF, Chan CP, Lin
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Chiapasco M, Rossi A, Motta JJ, Crescentini M (2000)
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Vayvada H, Mola F, Menderes A, Yilmaz M (2006)
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Enislidis G, Fock N, Sulzbacher I, Ewers R (2004) of the posterior disc attachment following arthrotomy
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Imaging the Postoperative Neck
10
Daniel Thomas Ginat, Elizabeth Blair,
and Hugh D. Curtin
10.1 Reconstruction Flaps pharyngeal closure. Pectoralis myocutaneous

flaps can also be “tubed” to create a neopharynx,
10.1.1 Discussion in which there is a deep core of fatty tissue, a more
superficial area of the muscle, and overlying skin
Flap reconstruction is routinely performed for that forms the “pseudomucosa.” Initially, the myo-
closing soft tissue, bone, and/or skin defects cre- cutaneous flaps maintain muscle bulk, but often
ated by head and neck tumor resection. Many gradually become atrophied and replaced by fat.
donor sites and types of flaps are available includ- Osteomyocutaneous and bone grafts are
ing local, regional, and free flaps (Figs. 10.1, mainly used to reconstruct mandibulectomy
10.2, 10.3, 10.4, 10.5, 10.6, 10.7, 10.8, 10.9, defects. The fibula is a common donor site, but
10.10, and 10.11 and Table 10.1). the scapula, ribs, and other bones can be used as
The pectoralis major muscle flap is often used well. The bone grafts are often cut into smaller
as a rotation flap for head and neck reconstruction sections in order to reconstruct the curved con-
surgery. Due to the highly vascular nature of the tours of the mandible. The grafts are usually
pedicled pectoralis major flap, it is desirable for secured using plates and screws. The soft tissues
repairing defects in previously radiated areas. The attached to the bone flaps are useful for providing
pedicled flap is brought over the clavicle with its bulk to large surgical defects.
vascular supply and is often used to provide cov- Colon interposition, gastric pull-through, and
erage of the carotid arteries or to reinforce primary jejunal/ileal grafts have been used to reconstruct
the upper aerodigestive tract after procedures that
involve resection of part or all of the pharynx
Department of Radiology, University of Chicago, and/or esophagus, such as with pharyngolaryn-
Chicago, IL, USA goesophagectomy. On imaging, rugal folds and
e-mail: dtg1@uchicago.edu haustra can be identified with gastric and colon
E. Blair, M.D. interposition, respectively. Alternatively, muscu-
Department of Surgery, Section of Otolaryngology- lomucosal flaps, such as the FAMM flap, can be
Head and Neck Surgery, University of Chicago,
Chicago, IL, USA
used to reconstruct relatively superficial upper
aerodigestive tract defects.
H.D. Curtin, M.D.
Imaging with CT, MRI, and 18FDG-PET is
Boston, MA, USA routinely used for posttreatment imaging, partic-
Department of Radiology, Massachusetts Eye and Ear
ularly for tumor surveillance. Recurrence can be
Infirmary, Boston, MA, USA difficult to discern due to the altered anatomy of

DOI 10.1007/978-3-319-52341-5_10
the surgical bed on CT or MRI ((Fig. 10.12), such

as the soft tissue components of the flaps. 18FDG-
PET/CT is particularly helpful in such instances,
but is ideally performed no sooner than 12 weeks
following surgery in order to minimize the rate of
false-positive results. However, it is helpful to
obtain a baseline CT or MRI soon after surgery
for subsequent comparison and to correlate the
findings with the operative note.
While serosanguinous fluid collections or
seromas in the surgical bed after flap reconstruc-
tion are commonly encountered on early postop-
erative imaging, large perioperative hematomas
are rare. However, these can lead to flap isch-
emia; therefore, prompt recognition and re-
exploration can help salvage the flap. On CT, the
hematomas can appear as mass-like heteroge-
neous lesions (Fig. 10.13).
Infection of the flap is a serious complication,
which may require urgent debridement or revi-
sion. Diagnostic imaging is useful for delineat-
ing the extent of the infected fluid collections,
which can contain gas, have peripheral enhance-
ment, and surrounding fat stranding (Fig. 10.14).
Infections in the surgical bed can be predisposed
by the presence of fistulas with the skin and/or
aerodigestive tract.
Anastomotic leaks are potential sources for
infection. CT or fluoroscopic examinations with
oral contrast administration can be useful for
assessing the presence of leaks. The presence of
hyperattenuation from the oral contrast material
in extraluminal fluid collections is indicative of a
leak (Fig. 10.15). A baseline CT without oral Fig. 10.1 Illustration of various types of tissue flaps.
contrast can be useful for comparison, since sur- Fasciocutaneous (A). Musculomucosal (B). Myocutaneous
gically implanted hyperattenuating material can (C). Bowel (D). Bone/osteomyocutaneous (E)
potentially be misinterpreted as contrast.
10 Imaging the Postoperative Neck 455
a b
Fig. 10.2 Temporalis flap. Axial (a) and coronal (b) T1-weighted MR images show the characteristic fan-shaped
appearance of the flap that fills the right nasal cavity, maxillectomy cavity, and masticator space
a b
Fig. 10.3 Fasciocutaneous rotation advancement flap. fascia component of the graft (arrows) as a low-signal-
The patient has a large defect following Mohs surgery for intensity band. The rest of the graft demonstrates normal
a cutaneous malignancy of the left cheek. Axial fat signal intensity without evidence of recurrent disease.
T2-weighted MR images (a, b) demonstrate the Scarpa’s Atrophy of the left masticator muscles is noted
Fig. 10.5 Myocutaneous rotational flap. Axial CT image

shows a pectoralis flap swung over the clavicle to fill a
Fig. 10.4 Myocutaneous free flap. Axial CT image large surgical defect in the neck. The vascular pedicle is
shows the skin (arrow), fat (*), and muscle (arrowhead) visible (arrow), as are the muscle (arrowhead) and adi-
components of the thigh flap used to reconstruct the left pose tissue (*) components of the flap. The muscle has
oropharynx and oral cavity undergone fatty degeneration
a b
Fig. 10.6 Osteomyocutaneous flap. Axial (a) and 3D (b) CT images show left maxillofacial reconstruction using a
fibular graft (arrowheads) with surrounding soft tissues (arrows)
Fig. 10.7 Myocutaneous flap neopharynx. Axial CT Fig. 10.9 Colonic interposition. Axial CT image shows a
image shows skin lining the neopharynx (arrow), which is loop of large bowel (arrow) adjacent to the trachea
surrounded by subcutaneous fat and muscle
Fig. 10.10 Gastric transposition. Axial CT image shows

the transposed stomach filled with barium, which outlines
the rugal folds (arrow). Total pharyngolaryngoesophagec-
tomy was also performed
Fig. 10.8 Radial forearm free flap lip reconstruction.

Axial CT image shows lower lip reconstruction utilizing
radial forearm free flap and palmaris longus tendon
(arrow), which provides near-anatomic contours
a b
Fig. 10.11 Facial artery musculomucosal (FAMM) flap. coronal CT image (b) shows interval resection of the mass
Preoperative coronal CT image (a) shows an infiltrative and reconstruction with a flap that closely approximately
mass in the right floor of the mouth (arrow). Postoperative approximates the floor of the mouth
Table 10.1 Types of flap reconstruction

Components Type Description
Vascular supply Random Transected small vessels
Free Transected and reanastomosed large vessels
Pedicle Intact vascular supply with tissue rotated into position
Tissue Fasciocutaneous Composed of subcutaneous fat and fascia as well as
dermal/epidermal tissue
Myocutaneous Composed of muscle, subcutaneous, and dermal/
epidermal tissue. They are used to close large soft tissue
defects and may sometimes also be used to reconstruct
the aerodigestive tract. Common donor sites include
pectoralis major and the anterolateral thigh
Bone Used to reconstruct mandible defects. Common donor
sites include fibula, iliac crest, and scapula. May be used
as part of an osteomyocutaneous flap
Bowel Used for upper aerodigestive tract reconstruction and
includes jejunal and ilial grafts and gastric and colonic
interpositions
Musculomucosal Used to close small to moderate upper aerodigestive tract
mucosal defects, often using tissue supplied by the facial
artery (FAMM flap)
Fig. 10.13 Perioperative hematoma. Axial CT image

obtained shortly after laryngectomy shows a heteroge-
neous mass-like hematoma (arrow) underlying the edem-
b atous left pectoralis flap
Fig. 10.12 Tumor recurrence. Axial CT image (a) shows

a myocutaneous flap with subtle nodularity along the left
aspect of the neopharynx (arrow) in a patient with history
of head and neck squamous cell carcinoma, but no prior
baseline exams available. 18FDG-PET/CT (b) was rec-
ommended and obtained 2 weeks later, which shows cor-
responding marked hypermetabolism (arrow)
Fig. 10.14 Infected flap. Coronal fat-suppressed post-

contrast T1-weighted MRI shows a fluid collection with
surrounding enhancement (arrow) deep to the left neck
myocutaneous flap, which represents an abscess
a b
Fig. 10.15 Anastomotic leak. Axial (a) and sagittal (b) CT images obtained with intravenous and oral contrast show
the presence of extraluminal oral contrast (arrowheads) in a collection adjacent to the jejunal graft (arrows)
10.2 Neck Dissection section results in more c onspicuous flattening of

the neck contour and blurring of the tissue planes
10.2.1 Discussion than modified radical neck dissection. There may
also be reduced flow in the carotid artery due
Neck dissection is performed to diagnose and/or to surgical manipulation and radiation therapy.
remove at risk and/or diseased lymph nodes and, Rarely, the common carotid artery is sacrificed
in some cases, surrounding structures. The main during extended neck dissection. Myocutaneous
types of neck dissection include selective, modi- flaps are usually required to reconstruct large
fied, radical, and extended neck dissection defects resulting from radical and extended neck
(Table 10.2). Features of each of these can be dissection. Tissue flaps are also sometimes used
appreciated on CT (Figs. 10.16, 10.17, 10.18, to provide coverage of the external carotid artery
10.19, and 10.20). after modified radical neck dissection.
Postoperative imaging is usually performed Potential pitfalls in the interpretation of imag-
with contrast-enhanced CT and serves to identify ing after neck dissection has been performed are
clinically occult disease, which occurs in 7.5– cauterized adipose tissue and suture granulomas,
28% of cases. Per NCCN guidelines, a baseline which can be mistaken for lymphadenopathy.
study is usually obtained within about 6 months Cauterized adipose tissue can appear as nodu-
of surgery for comparison with subsequent stud- lar foci of soft tissue attenuation, but often con-
ies, which are usually obtained depending on serve some degree of fat attenuation centrally
symptoms, physical exam, and findings from pre- (Fig. 10.21). Suture granulomas can also appear
vious imaging. During the early postoperative as soft tissue nodules, but the occasional presence
period, local hemorrhage and edema are common of hyperattenuation centrally associated with the
findings for all types of neck dissection. These suture is a help clue (Fig. 10.22). In either case,
changes usually resolve by 6 weeks after surgery these conditions tend to remain static on serial
and have a reticular appearance on CT. Over imaging, as opposed to recurrent neoplasm.
time, there may be persistence of edema and Complications depend on the extent of neck
development of fibrosis, particularly if radiother- dissection. Denervation injury results in high
apy is administered. The degree of retropharyn- T2 signal and enhancement within the first few
geal edema can be exacerbated by resection of months and fatty atrophy and laxity on a chronic
the internal jugular vein. A stable postoperative basis. The more frequently encountered sites for
appearance may not be attained until denervation injury after neck dissection include
12–18 months after surgery. the trapezius muscle and the tongue (Fig. 10.23).
Following selective and modified radical neck Extensive neck dissection can potentially impair
dissection, atrophy of the sternocleidomastoid lymphatic drainage and lead to cervicofacial
and strap muscles is also common. In addition, edema, which appears as diffuse swelling and fat
removal of the adipose tissue and lymph nodes stranding (Fig. 10.24) and can be exacerbated by
around the carotid sheath decreases the space radiation therapy. Leakage of chyle from the lym-
between the sternocleidomastoid and internal jug- phatic system can result in lymphoceles, which
ular veins. The presence of scarring may accentu- typically appear as unilocular fluid collections
ate the degree of asymmetry and effacement of with thin walls (Fig. 10.25). Infections can occur
the fat planes. Nonvisualization of the ipsilat- in the skin and subcutaneous tissue as cellulitis
eral internal jugular vein occurs in about 20% and abscesses (Fig. 10.26). In addition, osteomy-
of cases of selective neck dissection and may be elitis of the clavicle can result from lower central
attributable to thrombosis and should be reported. compartment or supraclavicular lymph node dis-
Following removal of the ipsilateral submandibu- section (Fig. 10.27). This should not be confused
lar gland with level I dissection, the remaining with degenerative changes and effusions of the
contralateral submandibular gland should not be sternoclavicular joint due to altered biomechan-
misinterpreted as a lesion itself. Radical neck dis- ics and neuropathic joint (Fig. 10.28).
Table 10.2 Types of neck dissection

Type of neck dissection Description
Selective (Fig. A) Removal of selected lymph nodes between levels
I and V with preservation of the
sternocleidomastoid, internal jugular vein, and
spinal accessory nerve intact. There are four main
types of SND: supraomohyoid, anterior,
posterolateral, and lateral
Modified (Fig. B) Removal of levels I and V lymph nodes with

preservation of the sternocleidomastoid, internal
jugular vein, or spinal accessory nerve intact
Radical (Fig. C) Removal of selected lymph nodes from levels I

and V, sternocleidomastoid, internal jugular vein,
and spinal accessory nerve
Extended (Fig. D) Same as radical neck dissection along with
removal of another lymph node group (i.e.,
superior mediastinal) or nonlymphatic structure
(i.e., carotid artery) or structure not normally
included in neck dissection (i.e., salivary gland,
thyroid)
CCA common carotid artery, IJV internal jugular vein, LN lymph node, SCM sternocleidomastoid
a b
Fig. 10.16 Selective neck dissection. Axial CT image subcutaneous stranding. The sternocleidomastoid muscle
4 weeks after lateral neck dissection (a) shows a seroma and internal jugular vein are intact. Axial CT image (c)
(arrow) overlying the right sternocleidomastoid muscle. shows resection of the right submandibular gland and
There is loss of fat surrounding the carotid artery and sub- remaining left submandibular gland (arrow), producing
cutaneous tissues. Axial CT image obtained 2 years after an asymmetric appearance that should not be confused
right lateral neck dissection and radiotherapy (b) shows with a mass lesion
Fig. 10.18 Radical neck dissection. Axial CT image

shows the absence of the left sternocleidomastoid and
internal jugular vein as well as concavity of the left neck
contour
Fig. 10.19 Radical neck dissection with pectoralis rota-

Fig. 10.17 Modified radical neck dissection. Axial CT tional flap. Axial CT image shows right radical neck
image shows the absence of the right internal jugular vein dissection, including resection of the right sternocleido-
and atrophy of the sternocleidomastoid (S) and trapezius mastoid. Instead, there is a pectoralis rotational flap
(T) muscles but compensatory hypertrophy of the right (arrow) that covers the carotid artery
levator scapulae (L). There is also mild edema in the right
neck soft tissues
a b
Fig. 10.20 Extended neck dissection. Preoperative axial Postoperative axial CT image (b) shows interval sacrifice
CT image (a) shows an infiltrative tumor (arrow) that of the left common carotid artery and myocutaneous flap
encases the left carotid artery. The patient had undergone reconstruction
prior radical neck dissection and radiation therapy.
Fig. 10.22 Suture granuloma. AxialCT image after total

laryngectomy shows a nodule with a central highattenua-
tion focus (arrow)
Fig. 10.21 Cauterized adipose tissue. Axial CT image
shows a nodular area with central hypoattenuation in the
subcutaneous tissues of the right face (arrow), which rep-
resents biopsy-proven fibroadipose tissue
a b
c
d
Fig. 10.23 Denervation related to neck dissection. (arrow), ipsilateral to where neck dissection was per-
Coronal STIR (a), T1-weighted (b), and post-contrast formed. Axial CT image in a different patient (d) demon-
fat-suppressed T1-weighted (c) MR images show edema, strates fatty change in the left half of the tongue (arrow)
and enhancement is an atrophic right trapezius muscle after hypoglossal nerve sacrifice during neck dissection
Fig. 10.26 Wound abscess. There is a large gas and fluid

collection in the right neck surgical bed. There is also
overlying subcutaneous fat stranding and skin thickening
Fig. 10.24 Postoperative lymphedema. Sagittal CT

image shows diffuse swelling of the cervicofacial soft tis-
sues, particularly the tongue and lips, as well as diffuse fat
stranding
Fig. 10.27 Osteomyelitis. Axial CT image shows an

open wound and sinus tract with regional subcutaneous fat
stranding and erosion of the left medial clavicle (arrow)
Fig. 10.25 Lymphocele. Axial CT image shows a large,

unilocular fluid-attenuation collection (*) in the left neck
that extends into the left chest subcutaneous tissues
(Courtesy of John Wandtke, M.D.)
Fig. 10.28 Neuropathic joint. Coronal CT image (a)

shows radical right neck dissection and flap reconstruc-
tion. Axial CT image (b) shows right proximal clavicle
degenerative changes ipsilateral to the neck dissection
10.3 Parotidectomy cosmetic deformity, facial nerve deficits, sialo-

cele, wound infection, hematoma, and tumor
10.3.1 Discussion recurrence. In particular, recurrence of parotid
pleomorphic adenoma has an incidence of 1–5%
Parotidectomy is most commonly performed for and most commonly occurs within the first
primary salivary neoplasm resection, but is also 10 years following surgical resection. Recurrent
performed for oncologic management of skin lesions have fairly characteristic imaging fea-
cancers. Several types of parotidectomy can be tures. On T2-weighted MRI, the majority of
implemented, including superficial parotidec- recurrent tumors have very high signal intensity
tomy and total parotidectomy with or without due to myxoid contents. The presence of multiple
facial nerve preservation, depending on the type, subcentimeter nodules is a strong indicator of
size, and location of the tumor (Figs. 10.29, recurrence and is observed in about two-thirds of
10.30, and 10.31). The defects created by more cases. This feature results in a “bunch of grapes”
extensive resections can be reconstructed using appearance (Fig. 10.32). Recurrent pleomorphic
tissue flaps or synthetic materials. Furthermore, adenomas are sometimes located in the subcuta-
when the facial nerve is compromised, eyelid neous tissues or adjacent neck spaces perhaps
weights are often used to aid eye closure. due to spillage during surgery. The enhancement
In general, complications and expected conse- pattern is variable, depending upon the extent of
quences related to parotidectomy may include cystic components, fibrosis, and necrosis.
Fig. 10.29 Superficial parotidectomy with graft recon-

struction. Axial CT image shows fat graft occupying the
Fig. 10.30 Total parotidectomy. Axial T2-weighted MRI
expected location of the right superficial parotid lobe
shows the absence of the left parotid gland, resulting in
(arrowhead). The deep lobe of the right parotid gland
concavity of the overlying skin. The facial nerve could be
remains intact (arrow)
spared along with the retromandibular vein, and the con-
tralateral normal parotid gland is intact
a b
Fig. 10.31 Total parotidectomy with facial nerve sacri- dibular ramus was also performed. The axial CT image
fice. Axial T1-weighted MRI (a) shows the absence of the (b) shows a left eyelid weight (arrow), with considerable
left parotid gland and atrophy of the left facial muscles. metal streak artifact
Partial resection of the left masticator muscles and man-
Fig. 10.32 Recurrent parotid pleomorphic adenoma.

Coronal STIR MRI demonstrates a cluster of nodules with
a “bunch of grapes” appearance (arrow)
10.4 S
alivary Duct Stenting appear as tubular hyperattenuating structures on
and Endoscopic Stone CT and should not be misinterpreted as residual
Removal sialolithiasis. Occasionally, stone extraction can
be complicated by sialocele or even cutaneous
10.4.1 Discussion fistula formation due to the friability of the
inflamed tissues in the setting of acute sialadeni-
Salivary duct stones can be managed by sialendo- tis and sialodacryoadenitis. In such cases,
scopic extraction. Sometimes, plastic stents are imaging can be performed to assess for the extent
inserted after stone removal in order to reduce the of associated fluid collections and sinus tracts
risk of subsequent stenosis (Fig. 10.33). These (Fig. 10.34).
Fig. 10.34 Parotid cutaneous fistula after endoscopic

stone extraction. Axial T1-weighted MRI shows a
right face skin defect and sinus tract (arrow) extending
to the underlying parotid gland
Fig. 10.33 Submandibular duct stent. Axial (a) and 3D

CT (b) images show a hyperattenuating stent that passes
through the right submandibular duct (arrows)
10.5 Facial Reanimation movement. The free muscle flap is buried in the
subcutaneous tissues of the face extending from
10.5.1 Discussion the temporal fossa to the oral commissure region.
CT and MRI can demonstrate the intact muscle
Facial reanimation can be performed for treating fibers in the healthy grafts (Fig. 10.35). In addi-
the effects of chronic facial nerve paralysis. This tion, Doppler ultrasound is useful for evaluating
can be accomplished with techniques, such as the patency of the feeding artery and draining
functioning free muscle transfer or temporalis vein. Transfer of compound flaps containing
muscle transposition and suspension combined muscle and other tissue, such as the skin, can be
with suborbicularis oculi fat (SOOF) lift. Overall, performed for cases of complex facial paralysis
these techniques successfully restore smiles and that involve skin or soft tissue deficits after tumor
provide improvement in mouth function in most excision. Alternatively, tensor fascia lata and
patients. AlloDerm grafts can be used and also appear
Functioning free gracilis microneurovascular as soft tissue bands on imaging, but these do
muscle transfer is a form of dynamic facial not offer dynamic facial animation (Figs. 10.36
reanimation that can help restore facial tone and and 10.37).
a b
c
d
Fig. 10.35 Free gracilis muscle transfer. The patient had demonstrate the grafted muscle (arrows) within the right
right facial paralysis after right cerebellopontine angle face subcutaneous tissues. Doppler ultrasound images of the
schwannoma resection. Axial (a) and coronal (b) CT images graft artery (c) and vein (d) display normal waveforms
Temporoparietal fascia and temporalis muscle procedure can be augmented using Silastic pros-
transposition and suspension procedures consist theses to fill the defect. Alternatively, the muscle
of detaching and repositioning the flap approxi- can be extended using polytetrafluoroethylene.
mately 180° inferiorly toward the oral commis- The suborbicularis oculi fat (SOOF) lift
sure and/or nasolabial folds via a tunnel through involves superior mobilization of midface
subcutaneous tissues (Figs. 10.38 and 10.39). The structures, which are fastened to the orbital rim
tissues superficial to the plane of dissection can using a variety of approaches (Fig. 10.40). Often,
be translated superomedially and sutured to the the intraorbital fat pads are also released and
fascia of the temporalis muscle. If necessary, the sutured to the SOOF.
Fig. 10.36 Tensor fascia lata graft. Axial CT image

shows the band-like graft positioned in the right face sub-
cutaneous tissues, inserting into the oral commissure
(arrow)
Fig. 10.37 AlloDerm graft. The patient is status post

total left parotidectomy with facial nerve sacrifice. Axial
CT image shows the soft tissue attenuation sling (arrow)
in the left check subcutaneous tissues
Fig. 10.38 Temporoparietal fascia and muscle flap. The

patient has a history of left facial paralysis. Coronal CT
image shows the flap swung inferiorly over the zygomatic
arch (arrow). There is considerable soft tissue swelling at
the surgical site
a b
c
d
Fig. 10.39 Temporalis muscle transposition and subor- MR images from superior to inferior (a–c) and a sagittal
bicularis oculi fat (SOOF) lift. The patient had left facial T2-weighted FLAIR image (d) show the left temporalis
paralysis status post parotidectomy and facial nerve resec- (arrows) turned inferomedially toward the mouth. The
tion for adenoid cystic carcinoma. Serial axial T2-weighted suborbicularis oculi fat pad has also been raised
Fig. 10.40 Schematic of the temporalis transposition technique. In the temporalis transposition (A), the temporalis
muscle is detached from the calvarium and brought inferomedially over the zygoma toward the oral commissure and
nasolabial folds. In the SOOF lift (B), the suborbicularis oculi fat pad is repositioned superiorly
10.6 O
ral Cavity Tumor Resection radial forearm flaps, FAMM flaps, submental
and Reconstruction island flaps, and acellular dermal matrix, or a
combination of these.
10.6.1 Discussion The role of imaging after glossectomy is to
evaluate complications, such as infection, sialo-
Depending on the stage of oral tongue malignan- cele, and tumor recurrence (Figs. 10.46, 10.47,
cies, such as squamous cell carcinomas, variable and 10.48). Of note, one must be particularly
degrees of glossectomy may be performed, rang- vigilant for the presence of perineural tumor

ing from partial, subtotal, or total, with or with- spread on imaging before and after surgery,
out floor of the mouth resection, mandibulectomy, especially following resection of salivary gland
and laryngectomy (Figs. 10.41, 10.42, 10.43, malignancies, which is often along the maxillary
10.44, and 10.45). Of note, composite tumor division branches of the trigeminal nerve for oral
resection consisting of glossectomy, mandibulec- cavity tumors. Furthermore, since radiation often
tomy, and neck dissection known as “Commando,” accompanies surgical treatment of oral cancers,
an acronym for combined mandibulectomy and the mandible is at risk for osteonecrosis. This
neck dissection operation, can be performed for complication tends to occur at least 1 year after
advanced cancers of the oral cavity. Furthermore, radiation therapy and appears as areas of cortical
the submandibular gland may be removed with irregularity and lucency (Fig. 10.49). There can be
rerouting of the duct as part of the approach or as superimposed infection and pathological fracture.
part of the combined suprahyoid neck dissection.
Alternatively, the submandibular gland may be
the main target of surgery when it is involved by
primary salivary gland neoplasms. There are a
variety of options for reconstructing surgical
defects in the oral cavity region, including myo-
cutaneous flaps, such as single or double bilobed
Fig. 10.42 Subtotal glossectomy. The patient had a his-

Fig. 10.41 Partial hemiglossectomy with primary clo- tory of squamous cell carcinoma of the tongue. Axial CT
sure. Coronal fat-suppressed post-contrast T1-weighted image shows that the majority of the oral tongue has been
MRI shows a defect in the left lateral tongue (arrow), resected and reconstructed using a myocutaneous graft
without graft reconstruction resulting in asymmetric (arrow). Surgical clips are present along the margins of
prominence of the normal right side of the tongue the graft
Fig. 10.43 Total glossectomy and laryngectomy. The

patient had a history of chemoradiation for stage IV
squamous cell carcinoma of the base of the tongue.
Subsequently, total laryngectomy and total glossectomy
with myocutaneous flap reconstruction were performed.
Sagittal CT image demonstrates complete absence of the
native tongue with placement of a myocutaneous flap with
predominantly fat attenuation components (arrow). The
flap provides near-anatomic contours for the reconstructed
tongue
Fig. 10.45 Floor of mouth resection with marginal man-

dibulectomy. Sagittal CT image shows extensive resection
of the floor of mouth contents along with the gingiva and
alveolar portions of the mandible. The defect has been
reconstructed using a myocutaneous flap
Fig. 10.44 Commando. Coronal CT image shows glos-

sectomy, and right hemimandibulectomy with flap recon-
struction. Neck dissection, which is not shown, was also
performed
Fig. 10.46 Sialocele after floor of mouth resection and

submandibular duct rerouting. Axial CT image shows a
well-defined fluid collection in the right submandibular
space (arrow)
Fig. 10.47 Locoregional tumor recurrence. Axial CT

images (a, b) show recurrent tumor (arrow) at the glos-
sectomy site (*) as well as bilateral lymphadenopathy
(arrowheads) from metastatic squamous cell carcinoma
Fig. 10.48 Perineural tumor. Axial fat-suppressed post-

contrast T1-weighted MRI shows marked expansion of a
branch of the right maxillary division of the trigeminal
nerve that represents perineural tumor (arrow) that
remained after resection of a submandibular gland ade-
noid cystic carcinoma at another institution
Fig. 10.49 Mandibular osteonecrosis. Axial CT image

shows extensive irregular lucency on the mandible after
radiation and floor of mouth tumor resection
10.7 Tonsillectomy pharyngeal wall, they can be considered markedly

and Adenoidectomy enlarged (Fig. 10.52). On the other hand, patients
can develop velopharyngeal insufficiency follow-
10.7.1 Discussion ing excessive removal of adenoid tissues. This can
manifest as a gap between the pharynx and soft
Tonsillectomy and adenoidectomy are two of the palate on cine MRI, which can be treated via pala-
most commonly performed pediatric surgical pro- toplasty or pharyngeal augmentation with sub-
cedures. The main indications for tonsillectomy stances, such as hydroxyapatite filler (Fig. 10.53).
and adenoidectomy include adenotonsillar hyper- Among patients who underwent tonsillectomy/
plasia with obstructive sleep apnea, failure to adenoidectomy for neoplasm, 18FDG-PET/CT is
thrive, or abnormal dentofacial growth; malignant useful for evaluating recurrent tumor. However,
neoplasms; and adenotonsillar hyperplasia with infection at the site of surgery can manifest as focal
upper airway obstruction, dysphagia, or speech hypermetabolism (Fig. 10.54). Noninfectious
impairment and halitosis. Furthermore, otitis inflammation and granulation tissue at the surgical
media and recurrent or chronic rhinosinusitis or site can also yield false-positive results on 18FDG-
adenoiditis are indications for adenoidectomy, but PET/CT. However, as opposed to tumor recurrence,
not tonsillectomy, while recurrent or chronic pha- activity on 18FDG-PET/CT should decrease over
ryngotonsillitis, peritonsillar abscess, and strepto- time with infection and inflammation.
coccal carriage are indications for tonsillectomy,
but not adenoidectomy. Frequently, the appear-
ance on postoperative imaging is that of asym-
metric absence of Waldeyer ring tissue, whereby
the residual normal tissue can hypertrophy and
should not be mistaken for a lesion (Fig. 10.50).
Sometimes, the trace amounts of residual
Waldeyer ring tissues can regrow over the course
of years after tonsillectomy/adenoidectomy, such
that the effects of surgery are not noticeable. As in
many other parts of the head and neck, when more
extensive surgeries are performed for tumor
resection, the resulting defects may be recon-
structed using soft tissue flaps (Fig. 10.51).
Among patients who underwent tonsillectomy
for obstructive apnea, cine MRI is a useful modal-
ity for evaluating anatomy and function when
there are recurrent symptoms. Potential causes
include glossoptosis, hypopharyngeal collapse,
recurrent and enlarged adenoids and lingual ton- Fig.10.50 Tonsillectomy. Axial fat-suppressed T2-weighted
MRI shows the absence of the right lingual tonsil and a
sils, and macroglossia. If lingual tonsils were remaining hypertrophied left anterior palatine tonsil
greater than 10 mm in diameter and abutted both (arrow). The postoperative changes are otherwise virtually
the posterior border of the tongue and the posterior imperceptible
Fig. 10.51 Tonsillectomy with flap reconstruction. Axial

CT images show flap reconstruction of the right tonsil-
lectomy defect (arrow), after resection of an invasive
squamous cell carcinoma. There is nevertheless a relative Fig. 10.52 Recurrent enlargement of adenoids and ton-
paucity of tissue on the right side sils. Cine MRI in a child with obstructive apnea previ-
ously treated with adenotonsillectomy shows enlarged
adenoid and lingual tonsils associated with airway nar-
rowing (encircled)
a b
Fig. 10.53 Velopharyngeal insufficiency after adenoid- gap that persists throughout the cycle (arrow). Sagittal
ectomy. The patient underwent a Furlow palatoplasty to MR image (b) obtained after adenoid augmentation shows
repair a submucosal cleft with marked improvement but increased bulk of the adenoids with no residual velopha-
persistent velopharyngeal insufficiency with fatigue at the ryngeal gap. Axial CT image (c) in a different patient
end of the day. Posterior pharyngeal wall pharyngoplasty shows the high attenuation Radiesse within the retropha-
with calcium hydroxyapatite filler injection augmentation ryngeal space at the level of the oro- and nasopharynx
was then performed. Sagittal cine MR image (a) after (arrow)
adenoidectomy and palatoplasty shows velopharyngeal
a b
Fig. 10.54 Postoperative infection mimicking tumor left oropharyngeal surgical bed (arrow). The lesion
recurrence. Contrast-enhanced CT (a) shows asymmetric proved to be fungal pharyngitis, and follow-up 18FDG-
edema of the pharyngeal mucosal and parapharyngeal PET/CT (c) obtained 6 months later showed resolution of
spaces (arrow), but no distinct mass. 18FDG-PET/CT (b) the lesion
obtained soon after shows focal hypermetabolism in the
10.8 Transoral Robotic Surgery during the first weeks to months after surgery,
retraction of the tongue base bed is apparent on
10.8.1 Discussion postoperative imaging (Fig. 10.55), without evi-
dence of solid enhancement. A radical tonsillec-
Transoral robotic surgery (TORS) is a minimally tomy using a TORS approach involves the tonsil,
invasive technique that involves the use of endo- anterior and posterior tonsillar pillars, portions of
scopic visualization and dexterous robotic arms the soft palate, tongue base, to encompass the
and has been mainly implemented for resecting superior constrictor muscle as the depth of resec-
T1 and T2 squamous cell carcinomas of the oro- tion and the posterior pharyngeal wall are
pharynx, although various other applications resected. Imaging during the first several postop-
have been explored. TORS offers a high rate of erative weeks typically demonstrates distortion
preserved postoperative swallowing function, but of the fat planes around the medial pterygoid
low incidence of complications. The postopera- muscle and retropharyngeal edema (Fig. 10.56),
tive imaging findings to TORS generally differ which can result from retraction or thermal injury
from those related to open surgery. Tongue base during the surgery. Over the ensuing months, scar
tumor TORS resection typically includes approx- tissue formation leads to gradual retraction of the
imately the half of the tongue base on the side of lateral oropharyngeal wall, with “tilting” of the
the tumor, with dissection to the circumvallate soft palate toward the surgical bed.
papillae and glossotonsillar sulcus. Consequently,
a b
Fig. 10.55 TORS base of tongue tumor resection. surgical bed (arrow) without evidence of tumor, but resid-
Preoperative axial CT image (a) shows a right oropharyn- ual normal hypermetabolic left lingual tissue, which
geal tumor (encircled). Postoperative axial 18FDG-PET/ should not be misinterpreted as tumor
CT image (b) shows retraction of the right tongue base
a b
Fig. 10.56 TORS lateral oropharyngectomy. CT image (b) shows interval resection of the tumor and
Preoperative axial CT image (a) shows a right palatine edema in the region of the surgical bed, with extension
tonsil squamous cell carcinoma (arrow). Postoperative into the retropharyngeal space (encircled)
10.9 Sistrunk Procedure amounts of the central portion of the hyoid bone,
following the cyst tract to the base of the tongue
10.9.1 Discussion (Fig. 10.57). This surgical technique has not sig-
nificantly changed since it was first described in
The Sistrunk procedure is performed for resec- 1920. Complications occur in 7.5% of cases and
tion of thyroglossal duct cysts and neoplasms. mainly include cyst recurrence and infection
The procedure includes removal of the variable (Figs. 10.58 and 10.59).
a b
Fig. 10.57 Sistrunk procedure. Axial CT (a) and 3D (b) CT images show surgical defects in the midportion of the
hyoid bone in two different patients
a b
Fig. 10.58 Recurrent thyroglossal duct cyst. Axial (a) and sagittal (b) CT images show a midline fluid collection with
a tract that extends from the Sistrunk resection site (arrows)
Fig. 10.59 Abscess after Sistrunk procedure. Axial CT

image shows a rim-enhancing fluid collection at the site of
hyoid bone resection (arrow)
10.10 Laryngectomy and imaging features are depicted in Figs. 10.60,

10.61, 10.62, 10.63, 10.64, 10.65, and 10.66 and
10.10.1 Discussion listed in Table 10.3. There is an increasing trend
towards laryngeal conservation procedures in
A wide variety of laryngectomy procedures can be order to preserve function. Laser photoangiolysis
performed, depending on the size and location of can effectively remove tumors of the vocal cords,
tumor within the larynx, ranging from conserva- which can then heal with near-anatomic configu-
tive to radical. CT is often used to follow patients ration. In addition, reconstruction of the laryngeal
who underwent laryngectomy. The types of lar- framework can be performed during laryngec-
yngectomy with their corresponding descriptions tomy using materials such as aortic grafts.
b
Fig. 10.61 Complex laryngectomy with aortic graft
reconstruction. Axial CT image shows partial laryngec-
tomy with soft tissue spanning the anterior tracheal carti-
lage defect, which represents the aortic graft (arrow)
Fig. 10.60 Angiolytic laser cordectomy. Preoperative

axial CT image (a) shows a right glottic carcinoma
(arrow). Postoperative axial CT image (b) shows interval
resection of the mass and minimal asymmetry of the
neocord
Fig. 10.62 Vertical partial laryngectomy. Axial (a),

a
coronal (b), and 3D (c) CT images show
hemilaryngectomy with the absence of the right
thyroid cartilage and thyroarytenoid (arrowheads).
The neovestibule is asymmetric. The contralateral
thyroid cartilage and thyroarytenoid remain intact
c
a b
Fig. 10.63 Horizontal laryngectomy. Coronal (a) and fat, and asymmetry of the neovestibule. The hyoid bone
sagittal (b) CT images show supraglottic laryngectomy (arrow) abuts the residual thyroid cartilage (arrowhead)
with the absence of the epiglottis, absence of preepiglottic
a b
Fig. 10.64 Supracricoid laryngectomy with cricohyoidopexy. Axial (a) and sagittal (b) CT images show the hyoid
(arrows) closely apposed to the cricoid (arrowheads) with absence of the thyroid cartilages
a a
Fig. 10.66 Total pharyngolaryngectomy. Axial (a) and

Fig. 10.65 Total laryngectomy. Preoperative sagittal CT coronal (b) CT images show total resection of the larynx
image (a) shows a large laryngeal squamous cell carci- and hypopharynx with flap reconstruction, resulting in a
noma (*). Postoperative sagittal CT image (b) shows the neopharynx
absence of the laryngeal framework and hyoid bone. A
tracheostomy has been created (arrow)
Table 10.3 Types of laryngectomy

Procedure Description Imaging features
Conservative Microsurgery Minimally invasive excision of CT may appear normal
small tumors using lasers. Mainly once vocal cord tissue
used for excision of vocal cord regenerates. On CT, a
tumors and variable portions of defect in the vocal cord
the vocal cord (cordectomy) may be visible, but may
appear normal once vocal
cord tissue regenerates,
resulting in a pseudocord
Vertical partial laryngectomy Frontolateral laryngectomy: Frontolateral
resection of vertical segment of laryngectomy: CT shows
thyroid cartilage, one vocal cord, vertical defect in thyroid
the laryngeal ventricle and false lamina, with irregular
cord, anterior commissure, and sclerotic border, absent
small anterior portion of aryepiglottic fold,
contralateral cord paraglottic and
preepiglottic fat, scar at
site of excised true vocal
cord that extends from the
contralateral thyroid
cartilage to the ipsilateral
arytenoid area that forms
pseudocord, tilting of
neovestibule to the side of
the major excision, and
normal subglottic larynx
Hemilaryngectomy: resection of Hemilaryngectomy: CT
same structures as in frontolateral shows similar findings as
laryngectomy and mucosa from with frontolateral
the aryepiglottic fold to the upper laryngectomy.
border of the cricoid cartilage, Reconstruction with tissue
arytenoid cartilage, and grafts or prostheses may
ipsilateral thyroid lamina be identified
Horizontal laryngectomy Supraglottic laryngectomy: Supraglottic
resection of epiglottis, laryngectomy: CT at the
aryepiglottic folds, false vocal supraglottic level shows
cords, upper third of thyroid dilated cavity. The hyoid
cartilage, and thyrohyoid and remaining thyroid
membrane cartilage are visible in the
same axial section. The
glottic and subglottic
structures are normal
Supracricoid laryngectomy: Supracricoid
resection of laryngeal structures laryngectomy: CT shows
from the cricoid cartilage to the soft tissue replacing false
hyoid bone with preservation of and true vocal cords and
at least one arytenoid cartilage surrounding the arytenoid
and cricohyoidopexy or cartilage. The neoglottis is
cricohyoidoepiglottopexy asymmetric and has a
reconstruction pseudocord appearance
Near-total laryngectomy Resection of entire larynx except CT can demonstrate the
for portions of thyroid lamina, laryngeal remnants. A
thyroarytenoid muscle, and entire tracheostomy in lower
arytenoid cartilage and recurrent neck is present
laryngeal nerve on one side
Procedure Description Imaging features
Radical Total laryngectomy Removal of the epiglottis, CT shows the absence of
aryepiglottic folds, true and false entire larynx, hyoid,
vocal cords, subglottic larynx, variable portions of the
hyoid bone, thyroid cartilage, tracheal rings, and part or
arytenoid cartilages, cricoid all of the thyroid glands.
cartilage, and one or more The neopharynx appears
tracheal rings. In addition, a as a concentric layer of
partial or total thyroidectomy is soft tissue. Excess tissue
often performed as well at the anastomosis can
resemble the epiglottis
(“pseudoepiglottis”). A
tracheostomy is invariably
present
Pharyngolaryngectomy In addition to total laryngectomy, The flap or graft material
there is more extensive resection that spans the surgical
of the pharynx, such that primary defect can be visualized,
anastomosis between the connecting the esophagus
esophagus and remaining inferiorly with the
portions of the pharynx is not remaining pharyngeal
feasible. Rather, flap or graft mucosal tissue superiorly.
reconstruction is performed to The graft has a tubular
create a neopharynx configuration that forms a
lumen (neopharynx). A
tracheostomy is also present
Complications following laryngectomy

include mass-like formations of granulation tis-
sue, which can mimic tumor recurrence
(Fig. 10.67); infection, which can lead to the
carotid artery blow out (Fig. 10.68); tumor recur-
rence, which can be associated with development
of pharyngocutaneous fistula (Fig. 10.69), par-
ticularly with concomitant radiation therapy; and
laryngoceles in the setting of laryngeal frame-
work conservation surgery (Fig. 10.70).
Fig. 10.68 Recurrent tumor with pharyngocutaneous fis-

tula. Sagittal CT image shows a fistulous tract (arrow) that
extends from the hypopharynx to the overlying skin filled
with injected contrast, traversing necrotic recurrent tumor
Fig. 10.67 Granulation tissue. Axial CT image shows a

mildly enhancing soft tissue nodule (arrow) in the left
anterior commissure where partial laryngectomy and aor-
tic graft reconstruction were performed
a b
Fig. 10.69 Carotid blowout. Axial (a) and curved planar well as radiation therapy. There is also an outpouching
reformatted (b) CTA images show a fluid and gas collec- (arrows) at the right carotid bulb, compatible with
tion surrounding the right carotid artery following laryn- pseudoaneurysm
gectomy and neck dissection with flap reconstruction, as
Fig. 10.70 Postoperative laryngocele. Axial CT image

shows a lobulated fluid collection (arrow) extending later-
ally beyond the larynx following partial laryngectomy
10.11 Tracheoesophageal saliva from entering the trachea, but allow air to
Puncture and Voice pass into the esophagus to enable “esophageal
Prostheses speech” (Fig. 10.73). The devices are usually
changed after several months due to biofilm
10.11.1 Discussion accumulation. Complications related to voice
prostheses are uncommon, but migration/malpo-
Voice prostheses (tracheoesophageal puncture sition, leakage around the valve, and valve
devices), such as Provox and Blom-Singer, are incompetence can occur. In addition, they can
used to provide voice restoration following total become dislodged and aspirated into the trachea
laryngectomy (Figs. 10.71 and 10.72). These or swallowed, and may appear as a foreign body.
devices are implanted across a surgical tracheo- CT with multiplanar reformations can be used
esophageal puncture or fistula created at the effectively to evaluate position of the prosthesis,
superior aspect of the tracheal stoma. Voice pros- since the cylindrical plastic and metallic compo-
theses contain a one-way valve that prevents nents are readily visible (Fig. 10.74).
a b
Fig. 10.71 Provox voice prosthesis. Axial (a) and sagittal (b) CT images show the voice prosthesis, the trachea (T),
and the esophagus (E) at the level of the stoma (oval)
Fig. 10.72 Blom-Singer voice prosthesis. Sagittal CT

image shows the prosthesis with its characteristic “duck-
bill” in the tissue plane between the trachea (T) and esoph-
agus (E)
Fig. 10.73 Illustration depicts a voice prosthesis and rel-

evant anatomy
a b
Fig. 10.74 Voice prosthesis migration. Oblique axial (a) and sagittal (b) CT images show anterior displacement of the
device, which does not attain the esophageal lumen (arrows)
10.12 Montgomery T-Tubes lesions, such as tracheal stenosis, tracheomala-

cia, and tracheal injury. Perhaps the main compli-
10.12.1 Discussion cation is subglottic granulation tissue formation,
which can be treated by laser therapy. In addition,
Montgomery T-tubes are silicone tubes that have these tubes are at risk for mucus plugging and
three limbs extending into the subglottic larynx, occlusion, which may not be recognized clini-
trachea, and tracheostomy (Fig. 10.75). T-tubes cally in the emergency department.
are used to manage complex laryngotracheal
Fig. 10.75 Montgomery® T-tube. Sagittal CT image

shows the limbs of the tube in the narrow subglottic lar-
ynx, trachea, and tracheostomy
10.13 Salivary Bypass Stent bypass stents serve as an effective way of diverting
and excluding the oral-alimentary stream. The
10.13.1 Discussion devices are also used as part of the repair of cervi-
cal esophageal and hypopharyngeal strictures and
Salivary bypass stents, such as the Montgomery® to facilitate the management of tracheoesophageal
salivary bypass tube, are long tubes composed of fistulae or esophageal disruption. Stents can be
silicone with a flanged superior end, which are secured with sutures or left unsecured, which may
hyperattenuating on CT (Fig. 10.76). Salivary predispose to migration into the intestinal tract.
a b
Fig. 10.76 Montgomery® salivary bypass tube. Axial (a) and sagittal (b) CT images show the salivary bypass stent
(arrows) positioned within the neopharynx. A tracheostomy tube is also present
10.14 Laryngeal Stents is soft and flexible enough to ensure a con-

forming fit while minimizing injury to soft tis-
10.14.1 Discussion sues. These stents are radioattenuating on CT
(Fig. 10.77). Montgomery stents can be used
The Montgomery® laryngeal stent is a molded for laryngotracheal support or for the treat-
silicone prosthesis that conforms to the ment of chronic aspiration. Laryngeal stenting
endolaryngeal surface and that is firm enough requires concomitant tracheostomy.
to support the endolarynx postoperatively yet
Fig. 10.77 Laryngeal stent. Sagittal CT image shows the

hyperattenuating silicon stent within the neolarynx
(arrows). A tracheostomy tube is also present
10.15 Laryngoplasty and Vocal include cartilage grafts (Fig. 10.80) and hydroxy-
Fold Injection apatite prostheses (Fig. 10.81).
A variety of agents are used for vocal cord
10.15.1 Discussion injection, including temporary, semipermanent,
and permanent agents (Table 10.4). These
Medialization laryngoplasty (thyroplasty) is a materials are injected into the thyroarytenoid
type of laryngeal framework surgery used to treat muscle or paraglottic space under laryngo-
vocal cord paralysis. The procedure consists of scopic guidance. The imaging features vary
creating a thyroid cartilage window and depending upon the specific agent used
implanting devices such as silicone (Montgomery) (Figs. 10.82, 10.83, 10.84, 10.85, and 10.86).
prostheses. The Montgomery vocal cord posi- Polytetrafluoroethylene implants demonstrate
tioning prosthesis is a triangular-shaped single heterogeneous hyperattenuation on CT and
block that is typically positioned deep to the thy- have irregular medial m argins. Silicone
roid cartilage (Fig. 10.78). However, the classic implants are also hyperattenuating, similar to
form of medialization laryngoplasty involves the adjacent thyroid cartilage. These materials
depressing the fragment thyroid cartilage at the are hypointense on T1 and T2 MRI sequences.
window and implanting the prosthesis superficial Fat grafts are characteristically radiolucent and
to this (Fig. 10.79). Other implantable materials hyperintense on both T1 and T2.
Fig. 10.78 Medialization laryngoplasty with

a
Montgomery prosthesis. Axial (a) and coronal (b) CT
images demonstrate the triangular silicone prosthesis
(arrows). There is rotation of the arytenoid and
medialization of the vocal cord
b
Complications of laryngoplasty include exces- airway compromise (Figs. 10.87, 10.88, 10.89,

sive or inadequate augmentation; foreign body 10.90, 10.91, and 10.92). Excess or inadequate
granuloma formation, particularly with Teflon; medialization is mainly a clinical judgment, and
implant rotation or lateralization; migration; and imaging is used for planning revision surgery.
Fig. 10.79 “Classical” laryngoplasty. Axial CT image

shows a silicone block implant (*) positioned superficial
to the depressed left thyroid cartilage fragment (arrow)
Fig. 10.81 Medialization laryngoplasty with hydroxy-
apatite prosthesis. Axial CT image shows a hyperattenuat-
ing right vocal cord implant (arrow) shaped to match the
contours of a normal vocal cord
Table 10.4 Types of agents used for vocal cord injection

Category Agents
Temporary Freeze-dried acellular
micronized human dermis
(Cymetra), hyaluronic
acid (Restylane), collagen,
Gelfoam
Semipermanent Calcium hydroxylapatite
(Radiesse), autologous fat
Permanent Silicone, Gore-Tex, Teflon
Fig. 10.80 Cartilage graft laryngoplasty. Axial CT image
shows a partially calcified tragal cartilage graft in the right
paraglottic space (arrow)
Fig. 10.82 Medialization laryngoplasty with polytetra-

fluoroethylene. Axial CT image shows the high-density
material with a cerebriform appearance (arrow) within the
right vocal fold producing medialization of the right vocal
fold
Fig. 10.83 Vocal fold augmentation with injectable cal-

cium hydroxylapatite (Radiesse). Initial axial CT image
(a) and PET/CT image (b) show the high attenuation
material within the right vocal cord with corresponding
hypermetabolism (arrows). Axial CT image (c) obtained
4 months later shows partial resorption of the filler mate-
rial (arrow)
a b
Fig. 10.84 Fat injection. Axial (a) and coronal (b) CT images show fat attenuation within the right vocal fold (arrows)
a b
Fig. 10.85 Vocal fold injection with hyaluronic acid. Doppler ultrasound image (b) shows a corresponding
Axial CT image (a) shows enlargement of the left vocal anechoic area without internal vascular flow (arrow)
cord with nearly fluid-attenuation material (arrow). The
Fig. 10.86 Vocal fold injection with micronized acellular

human dermis. Axial T2-weighted MRI shows curvilinear
hypointensity surrounded by diffuse high signal in the
enlarged left vocal fold (arrow)
Fig. 10.88 Laryngocele. Sagittal CT image shows a fluid

collection (arrow) above the vocal cord medialization
material
Fig. 10.87 Teflon foreign body granuloma. Axial CT

image shows mass-like soft tissue material surrounding
the left vocal cord implant (arrow)
Fig. 10.89 Laryngoplasty material extrusion. The patient

did not experience improvement after attempted laryngo-
plasty. Axial CT image shows lateral extrusion of the
implant (arrow) through the cartilage window and con-
cavity of the left vocal cord. The patient underwent subse-
quent revision laryngoplasty
Fig. 10.90 Montgomery prosthesis rotated into airway. Fig. 10.92 Insufficient medialization. The patient did not
Coronal CT image shows that the prosthesis projects too experience improvement in phonation after the surgery.
far into the airway (arrow). The patient presented with Axial CT image shows bilateral implants in position, but
hoarseness after trauma the rima glottidis is relatively wide. Revision surgery was
subsequently performed
Fig. 10.91 Laryngoplasty material supraglottic migra-

tion. Coronal CT image demonstrates superior extension
of the Gore-Tex (arrow) to the level of the right piriform
sinus and thickened aryepiglottic fold
10.16 Arytenoid Adduction rotated arytenoid and associated narrowing of the

posterior rima glottidis can be depicted on CT
10.16.1 Discussion (Fig. 10.93) and should not be mistaken for unin-
tended dislocation. Laryngeal edema is a com-
Arytenoid adduction was designed to enhance mon occurrence during the early postoperative
posterior glottal closure in patients with paralytic period, with a peak at 3 days after surgery,
dysphonia and may be performed in addition to although this does not generally result in airway
medialization laryngoplasty. The medially compromise.
a b
Fig. 10.93 Arytenoid adduction. Preoperative axial CT image (a) shows stigmata of left vocal cord paralysis. Postoperative
axial CT image (b) shows interval medial repositioning of the left arytenoid (arrow) along with the vocal cord
10.17 Arytenoidectomy vocal cord paralysis, ankylosis of the cricoaryte-

noid joint due to arthritis, and tumors of the ary-
10.17.1 Discussion tenoid cartilage. This can be accomplished
endoscopically via a submucosal approach or
Arytenoidectomy consists of removing the ary- laser surgery. Unilateral arytenoidectomy results
tenoid and is indicated for treating airway in asymmetric widening of the posterior airway
obstruction in patients with bilateral median (Fig. 10.94).
Fig. 10.94 Arytenoidectomy. The patient has a history of

bilateral vocal cord paralysis. Axial CT image shows the
absence of the left arytenoid (circle) resulting in asym-
metric widening of the otherwise narrow airway on the
left
10.18 Laryngeal Cartilage Remodeling CT is a suitable modality for evaluating the results
of the surgery and suspected complications, such
10.18.1 Discussion as submucosal hematomas. Panorex and 3D CT
are particularly useful for depicting the positioning
Laryngeal cartilage remodeling surgery can be of the hardware and alignment of the laryngeal car-
performed to treat deformities that result from tilages (Fig. 10.95). Postoperative hematomas are
trauma, laryngoplasty, or cancer and can be per- among the more common complications of laryn-
formed as part of sex change procedures. geal framework surgery and can be problematic if
Miniplates are commonly used for reconstruction. there is compromise of the airway (Fig. 10.96).
Fig. 10.96 Hematoma after cricoid cartilage repair.

Axial CT shows miniplate and screw fixation of an ante-
rior cricoid cartilage fracture. There is near-anatomic
alignment, but there is underlying submucosal swelling
that narrows the airway (arrow)
Fig. 10.95 Laryngeal framework reconstruction surgery.

Panorex (a) and 3D (b) reformatted CT images demon-
strate microfixation plates along the thyroid cartilage
10.19 Tracheotomy nulas, and an inflatable cuff. CT with multiplanar

reconstructions and volume renderings, such as
10.19.1 Discussion tissue transition projection, is a suitable method
for evaluating position of tube in relation to tra-
Tracheotomy is performed in order to secure the cheal wall (Fig. 10.97), tracheal stenosis, and
airway and consists of creating an opening various complications. Early complications
between the skin and trachea, or tracheostomy, related to tracheotomy and tracheostomy tubes
via open surgical or bronchoscopic techniques. include hemorrhage, infection, tube obstruction,
Once the passage is created and dilated, a trache- and placement into a false tract (Fig. 10.98),
ostomy tube is inserted. There are various types while late complications include tracheomalacia,
of tracheotomy tubes, but these commonly con- tracheoesophageal fistula, tracheoinnominate
sist of an obturator, curved inner and outer can- artery erosion, and tracheal stenosis (Fig. 10.99).
a b
Fig. 10.97 Tracheostomy tube. Sagittal CT image (a) jection CT image (b) demonstrated the narrowing of the
shows a tracheostomy tube in position for upper airway airway superior to the tracheostomy tube (arrow) to better
stenosis. The corresponding frontal tissue transition pro- advantage
a b
Fig. 10.98 Tracheostomy tube in a false tract. Axial (a) and sagittal (b) CT images show the tracheostomy tube tip
(arrows) positioned anterolaterally to the tracheal lumen
a b
Fig. 10.99 Post-intubation tracheal stenosis. Axial CT image (a) obtained during intubation and axial CT image (b)
obtained after removal of the endotracheal tube show interval narrowing of the tracheal lumen
10.20 Thyroidectomy tomy that can have correlate findings on diagnos-

tic imaging (Figs. 10.104, 10.105, and 10.106).
10.20.1 Discussion Furthermore, imaging plays an important role in
the postoperative evaluation for thyroid cancer.
Thyroidectomy consists of surgical resection of Ultrasound is generally suitable for evaluating
part or all of the thyroid glands for treating benign the region of the surgical bed region, whereby
and malignant conditions. The basic types of thy- tumor typically appears as hypoechoic or cystic
roidectomy are listed in Table 10.5 and depicted nodules that might contain microcalcifications,
in Figs. 10.100, 10.101, 10.102, and 10.103. especially with papillary thyroid carcinoma
The traditional approach for thyroidectomy (Fig. 10.107). However, CT, MRI, and in cases of
involves making a transverse incision several dedifferentiated thyroid cancer 18FDG-PET/CT
centimeters above the sternal notch. The use of are more sensitive for identifying recurrent tumor
robots and extracervical approaches, such as the that encroaches upon the trachea (Fig. 10.108),
axillary approach, has made minimally invasive which is a relatively common site of recurrence
thyroid surgery possible. due to the difficulty in completely resecting
Perioperative tracheal perforation, recurrent tumor in that area. Furthermore, these modalities
laryngeal nerve injury, hematoma, and infection are better suited for identifying retropharyngeal
are potential early complications of thyroidec- lymph node metastases (Fig. 10.109), which can
Table 10.5 Basic types of thyroidectomy

Type Description
Hemithyroidectomy (lobectomy) Removal of an entire lobe and isthmusectomy
Subtotal thyroidectomy Traditional technique: removal of the gland except for
approximately 2–3 g of tissue in the ipsilateral or bilateral
lower poles adjacent to the ligament of Berry
Hartley-Dunhill technique: ipsilateral total lobectomy and
isthmusectomy and subtotal resection on the contralateral
side, leaving up to approximately 5 g of tissue
Near-total thyroidectomy Removal of the gland except for less than 1 g of tissue in
the inferior poles adjacent to the ligament of Berry
Total thyroidectomy Removal of the entire gland
a b
Fig. 10.100 Subtotal thyroidectomy. Initial axial CT image (a) shows a goiter compressing the trachea. Postoperative
axial CT image (b) shows removal that the excess thyroid tissue has been removed and the trachea has re-expanded
be predisposed by altered lymphatic drainage fol- initial postsurgical scans is common. In particular,
lowing neck dissection. a thyroglossal duct remnant is apparent on post-
Iodine 131 total body scans play an important operative I-131 scintigraphy in about one-third of
role in the treatment and evaluation of local and patients after total thyroidectomy and appears as
distant tumor burden in patients with differentiated a midline linear band of increased activity supe-
thyroid cancer after surgery has been performed rior to the thyroid bed. This finding should not be
(Fig. 10.110). High doses of I-131 are admin- confused with metastases, since the presence of
istered to ablate any residual thyroid tissue after metastatic disease warrants even higher treatment
thyroidectomy, since it is usually not feasible to doses. The expected end point after successful
remove all thyroid tissues during thyroidectomy. therapy is the absence of activity in the thyroid bed
Activity in the region of the thyroid bed on the and other locations besides the salivary glands.
Fig. 10.103 Total thyroidectomy. Axial CT image shows

complete absence of the thyroid gland as well as the left
Fig. 10.101 Hemithyroidectomy. Axial CT image shows
strap muscles. The remaining right strap muscles (arrow)
a residual left thyroid lobe containing cysts (arrow) and
should not be confused for tumor
surgical clips in the right thyroidectomy bed
Fig. 10.102 Near-total thyroidectomy. Axial CT image

shows a small amount of residual posterior thyroid tissue Fig. 10.104 Thyroidectomy complicated by tracheal
adjacent to the tracheoesophageal grooves, right greater perforation. Axial CT images show extensive anterior
than left (arrows) neck emphysema after recent thyroidectomy and a defect
in the anterior wall of the trachea (arrow)
a b
Fig. 10.105 Vocal cord paralysis. Axial CT image at the Axial CT image at the level of the vocal cords (b) shows
level of the thyroid bed (a) shows left hemithyroidectomy ipsilateral left vocal cord atrophy secondary to left recur-
bed that extends into the left tracheoesophageal groove rent laryngeal nerve injury
along the expected course of the recurrent laryngeal nerve.
Fig. 10.107 Recurrent tumor in thyroidectomy bed.

Ultrasound image shows a hypoechoic mass with micro-
calcifications in the thyroidectomy bed in a patient with a
Fig. 10.106 Abscess. Axial CT image shows a fluid col- history of papillary thyroid carcinoma
lection in the anterior neck (*) extending from the thyroid
bed. Secondary signs of infection, including skin thicken-
ing, subcutaneous fat stranding, and reactive lymph nodes
are also apparent
Fig. 10.108 Recurrent papillary thyroid carcinoma.

Axial CT image shows an infiltrative mass in the left
thyroidectomy bed and tracheoesophageal groove
(arrow), with invasion of the tracheal lumen
10.21 Neck Exploration

and Parathyroidectomy
10.21.1 Discussion
Parathyroidectomy for parathyroid adenomas or

hyperplasia is typically performed either as uni-
lateral or bilateral neck exploration at the level of
the thyroid gland. Normal portions of parathyroid
gland that are encountered during exploration of
a parathyroid adenoma can be reimplanted in the
forearm, sternocleidomastoid, or subcutaneous
tissues of the neck, such that function is main-
tained (Fig. 10.111). Parathyroid adenoma recur-
rence and adenomas in ectopic parathyroid
glands are the main causes of failed neck explo-
ration (Figs. 10.112 and 10.113). It is also impor-
tant to be aware that adenomas can also arise in
glands that have been surgically repositioned
(Fig. 10.114). Options for imaging prior to re- Fig. 10.109 Postoperative retropharyngeal lymph node
exploration include technetium (99mTc) sestamibi metastasis. The patient has a history of papillary thyroid
carcinoma, status post thyroidectomy and neck dissection.
scanning, ultrasound, and four-dimensional (4D) Axial fat-suppressed T2-weighted MRI shows an abnor-
CT, or a combination of these. It has been mal right retropharyngeal lymph node (arrow)
reported that the sensitivity of 4D CT for local-
ization is 88% compared with 54% for sestamibi
imaging.
a b
Fig. 10.110 I-131 total body scans after thyroidectomy thyroglossal duct remnant (arrow) (b). Pulmonary meta-
and I-131 therapy. Normal scan without residual thyroid static disease (circle) (c)
activity (a). Residual activity in the thyroid bed and
Fig. 10.112 Residual hyperplastic parathyroid. Axial CT

image shows an avidly enhancing nodule (arrow) in the
Fig. 10.111 Parathyroidectomy with parathyroid gland left neck adjacent to surgical clips
autotransplantation. Sagittal CT image shows a parathy-
roid gland (arrow) implanted in the midline subcutaneous
tissues of the lower anterior neck
Fig. 10.114 Adenoma in a parathyroid gland previously

surgically transplanted along the sternocleidomastoid
muscle. Axial CT image shows a heterogeneous tumor
along superficial aspect of the right sternocleidomastoid
(arrow)
Fig. 10.113 Failed neck exploration due to ectopic para-

thyroid. The patient’s hypercalcemia and related symp-
toms persisted following bilateral neck exploration.
Coronal CT image shows a vertically elongated enhanc-
ing lesion along the carotid sheath superior to the thyroid
gland (arrow). The initial surgical exploration was per-
formed inferior and to the right of the lesion, as demar-
cated by the surgical clips
10.22 Brachytherapy typical brachytherapy systems consist of

radiation-emitting rods or needles that are
10.22.1 Discussion inserted via stereotactic navigation. Imaging may
be performed to assess placement and evaluate
Interstitial brachytherapy is sometimes per- tumor response. The rods appear as transcutane-
formed for treating head and neck malignancies. ous metallic density linear structures in the region
A variety of devices are available, although the of the lesion or resection bed (Fig. 10.115).
a b
Fig. 10.115 Brachytherapy rods. The patient has a his- sagittal (b), and coronal (c) CT images show an array of
tory of alveolar sarcoma of small parts in the right neck brachytherapy rods implanted in the region of the right
soft tissues, which was previously resected. Axial (a), neck resection cavity
10.23 Vagal Nerve Stimulation erator that is implanted beneath the

infraclavicular subcutaneous tissues. Unlike
10.23.1 Discussion with the right vagus nerve, left vagal stimulation
does not affect cardiac function. The most com-
Vagus nerve stimulation is an effective method mon side effects of vagus nerve stimulation
for controlling intractable seizures, with up to include sore throat and voice changes.
50% reduction in seizure frequency. The device Radiographs or CT may be performed to delin-
consists of two electrodes and an anchor loop eate the position and integrity of the electrodes
implanted in the left neck at the midcervical (Fig. 10.116). The vagal nerve stimulators are
level posterolateral to the internal and common considered MRI conditional and output currents
carotid arteries and medial to the internal jugu- should be programmed to 0 mA before entering
lar vein. The electrodes are connected to a gen- the MRI suite.
a b
Fig. 10.116 Vagal nerve stimulator. Fontal neck radio- region. Axial (b) and coronal (c) CT images show the
graph (a) shows left vagus nerve lead in position (arrow). components of the stimulator electrodes (arrows)
The pulse generator is partially shown in the left chest
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Imaging of Postoperative Spine
11
Daniel Thomas Ginat, Ryan Murtagh,
Per-Lennart A. Westesson, Marc Daniel Moisi,
and Rod J. Oskouian
11.1 Overview Postoperative imaging is generally obtained to

evaluate the position of implants, adequacy of
The main categories of spine surgery include sta- decompression, fusion status, and potential com-
bilization, decompression, disc replacement, as plications. The imaging findings of spine surgical
well as percutaneous vertebral augmentation and procedures, devices and implants, and complica-
other minimally invasive procedures (Table 11.1). tions are depicted throughout the chapter.

Chicago, IL, USA
R. Murtagh, M.D., M.B.A.
Department of Radiology, Diagnostic Imaging
Moffitt Cancer Center, Tampa, FL, USA
P.-L. A. Westesson, M.D., Ph.D., D.D.S.
M.D. Moisi, M.D., M.S. • R.J. Oskouian, M.D.
Department of Neurosurgery, Swedish Neuroscience

DOI 10.1007/978-3-319-52341-5_11
Table 11.1 Main types of spine surgery

Technique Description
Stabilization
Fusion (spondylodesis) Uniting portions of the spine via instrumentation and/or graft materials. A
variety of approaches can be implemented (anterior, lateral, posterior, etc.)
Distraction Halo, traction, interfacet, or interspinous process devices to provide
distractive force to vertebral column
Decompression
Laminotomy Partial removal of the lamina on one side
Hemilaminectomy Removal of a single lamina with exposure limited to one side of the
(unilateral laminectomy) interspinous ligament with decompression of one or both sides of the spinal
canal
Total laminectomy Removal of the bilateral lamina along with the spinous process
Laminoplasty Expansion of the spinal canal while preserving the dorsal laminar arch
Corpectomy Complete or partial removal of the vertebral body
Vertebrectomy (spondylectomy) Complete or partial removal of the vertebra
Foraminotomy Expansion of the neural foramen, usually via resection of part or all of the
facet
Facetectomy Resection of part or all of the facet
Discectomy/microdiscectomy Removal of herniated disc material
Miscellaneous
Disc and nucleus pulposus Dynamic reconstruction of the intervertebral disc with artificial disc or
replacement nucleus pulposus
Dynamic stabilization Various devices inserted into the disc space, interspinous space, or facet joints
Vertebroplasty, kyphoplasty, Minimally invasive injection of cement or device into vertebrae, or sacrum,
skyphoplasty, Kiva implantation, with or without balloon expansion
and sacroplasty
Nucleoplasty Radiofrequency ablation of herniated disc
Epidural blood patch Minimally invasive closure of dura for treatment of cerebrospinal fluid leaks
11 Imaging of Postoperative Spine 525
11.2 Spine Decompression notomy or discectomy. On imaging, widening of

interlaminar space can be identified, which is
11.2.1 Laminotomy often best identified in the coronal plane
and Foraminotomy (Fig. 11.1). These surgical defects often have
geometric margins. Sclerosis of the remaining
11.2.1.1 Discussion portions of the lamina can be observed, as heal-
Laminotomy consists of removing the margins of ing progresses. Similarly, foraminotomy, which
lamina and can be unilateral or bilateral. The spi- is performed for neural foraminal stenosis, can
nous process and interspinous ligaments are often appear as a generously sized neural foramen with
preserved; however, a partial resection of the spi- circular or rectilinear contours and irregular mar-
nous process may be necessary in order to facili- gins from shaving away of the surrounding corti-
tate the approach to the lamina. This procedure cal bone, which are best appreciated in the sagittal
can be performed to provide access for forami- plane (Fig. 11.2).
Fig. 11.1 Laminotomy. Coronal CT image demonstrates

thinning and of the left L4 and L5 lamina (arrows) result-
ing in a widened interspinous space
Fig. 11.2 Foraminotomy. Sagittal CT image shows an
artificially widening L5–S1 neural foramen (arrow)
11.2.2 Laminectomy infarct can result from disruption of the blood

supply to the spinal cord and acutely appears as
11.2.2.1 Discussion predominantly central high T2 signal with corre-
Hemilaminectomy or unilateral laminectomy sponding restricted diffusion on MRI (Fig. 11.8).
consists of resecting the lamina via dissection on This is due to hypoperfusion of the anterior spi-
one side of the interspinous ligament. This proce- nal artery. Additional complications related to
dure is mainly performed in order to gain access laminectomy are depicted in the “Failed Back
for foraminotomy or discectomy. The hemilami- Surgery” section.
nectomy defect is readily apparent on CT and
MRI, but can be of variable width (Fig. 11.3).
In some instances, when preservation of the a
interspinous ligament is necessary, after the uni-
lateral hemilaminectomy is performed, the liga-
mentum flavum is removed bilaterally for
bilateral decompression of the neural structures.
Bilateral laminectomy consists of removing
the spinous process along with both laminae,
thereby “unroofing” the posterior spinal canal.
This procedure is commonly performed for spi-
nal canal decompression, particularly related to
degenerative disc disease, spinal stenosis, epi-
dural infections, epidural or subdural hemato-
mas, and tumor. Bilateral laminectomy can be
performed in conjunction with other procedures
such as discectomy, facetectomy, and/or fusion
for restoring stability. Both CT and MRI can b
readily show changes related to laminectomy and
are routinely used to assess patients after surgery,
even in the presence of hardware (Fig. 11.4). If
the dura is opened (durotomy) or resected during
the procedure, duraplasty is often performed, in
which artificial dural replacement materials are
used (Fig. 11.5). Too tight closure of the dura or
duraplasty material can lead to compression of
the spinal canal contents. This can be evaluated
via MRI, in which there is concavity of the dura
or duraplasty material (Fig. 11.6). Spinal cord
contusions can occur secondary to decompres-
sion of severe stenosis. Contusions lead to typi-
cally transient and rarely permanent neurological
deficits, with severity depending on location,
Fig. 11.3 Hemilaminectomy. Axial (a) and coronal (b)
which can be delineated on MRI as T2 CT image demonstrates an opening in the left lamina
hyperintense lesions (Fig. 11.7). Spinal cord
(encircled)
a b
Fig. 11.4 Bilateral laminectomy. Axial (a) and sagittal (b) CT images show absence of the lamina and spinous pro-
cesses at L3 and L4 (encircled). There is also posterior fusion hardware
a b
Fig. 11.5 Laminectomy and duraplasty. Axial CT image (arrow). The sagittal T2-weighted MRI (b) shows that the
(a) shows hyperattenuating Gore-Tex duraplasty material duraplasty material has low signal (arrow), similar to nor-
that lines the posterior spinal canal at laminectomy site mal dura
Fig. 11.7 Spinal cord contusion. The patient woke up

with a right hemiparesis. Axial T2-weighted MRI shows
edema in the right lateral cortical spinal tract after cervical
laminectomy and fusion for cervical spine stenosis
Fig. 11.6 Tight durotomy closure. The patient experi-

enced worsening radiculopathy after surgery. Sagittal
T2-weighted MRI shows compression of the cauda equina
nerve roots by the dura (arrow) after recent laminectomy.
The patient returned to the operating room for release of
the durotomy repair and duroplasty with immediate relief
of symptoms
a b
Fig. 11.8 Spinal
cord infarct. The
patient experienced
paraplegia after
surgery. Sagittal
T2-weighted (a) and
DWI (b) MR images
show edema and
restricted diffusion
within the mid-
cervical spinal cord at
the same level of the
laminectomies
(arrows)
11.2.3 Facetectomy would be performed if an extra-foraminal

decompression and approach is required.
11.2.3.1 Discussion Various approaches can be used, including
Facetectomy is mainly performed as part of endoscopic, intertransverse, extra-foraminal,
treating far lateral disc herniations, facet hyper- and transpars techniques. The degree of bony
trophy, and limbus vertebral fractures. resection is best appreciated on CT, while MRI
Facetectomy can essentially be performed as is optimal for the assessment of nerve root
partial (usually medial) or total (Gil’s proce- decompression (Figs. 11.9 and 11.10). Scar tis-
dure). At times, a partial lateral facetectomy sue often fills the facetectomy defect.
a b
Fig. 11.9 Partial facetectomy. Preoperative axial CT image (a) shows bilateral facet degenerative changes.
Postoperative axial CT image (b) shows resection of the medial aspects of the bilateral facet joints
Fig. 11.10 Total facetectomy. Axial CT shows

complete absence of the right facet joint (*)
11.2.4 Microdiscectomy thereby preserving stability of the spinal column.

Clinical success of microdiscectomy is over 90%
11.2.4.1 Discussion at 6 months and over 80% at 10 years.
Microdiscectomy is a minimally invasive tech- Complications are uncommon and include
nique for treating symptomatic disc herniations infection, dural tear, nerve root injury, and resid-
and consists of curettage of disc material under ual or re-herniation of disc fragments. Imaging is
surgical microscope visualization typically done important for evaluating potential complications.
with a midline or paramedian approach Occasionally, hemostatic agents placed near the
(Fig. 11.11). Portions of ligamentum flavum are disc space can resemble a residual or re-herniated
often removed (flavectomy) in order to provide disc fragment, except these materials tend to have
adequate access to the disc and to contribute to lower signal on T1-weighted and T2-weighted
decompression of the spinal canal (Fig. 11.12). MRI sequences than does disc material
The posterior elements otherwise remain intact, (Fig. 11.13).
a b
Fig. 11.11 Microdiscectomy. Preoperative sagittal microdiscectomy shows interval resection of the herniated
T2-weighted MRI (a) shows a disc herniation at L5–S1 disc material, without significant alteration to the sur-
(arrow). Sagittal T2-weighted MRI (b) obtained after rounding structures
Fig. 11.12 Flavectomy. Axial T2-weighted MRI

shows absence of a portion of the left ligamentum
flavum (arrow)
a b
Fig. 11.13 Sagittal T2-weighted (a) and sagittal T1-weighted (b) MR images show low-intensity hemostatic material
packed into the left lateral recess just inferior to the operated disc space (arrows)
11.2.5 Laminoplasty using a burr to thin the contralateral lamina in order

to create a hinge and rotating the posterior elements
11.2.5.1 Discussion posterolaterally and often trimming the spinous
Laminoplasty is performed to widen the spinal processes (Fig. 11.14). Alternatively, “French
canal while preserving as much of the anatomy as door” osteotomy can be performed in which a
possible in order to conserve stability. Cervical trough is drilled bilaterally in the lamina and the
laminoplasty is recommended for the treatment of spinous process is split in half, opening up the spi-
cervical degenerative myelopathy or ossification of nal canal. The osteotomy gaps (“open door”) can
the posterior longitudinal ligament, with recovery be filled using bone or hardware (laminar prosthe-
rates of nearly 60% and improvement in about sis). Imaging may be performed after laminoplasty
80%. Commonly implemented surgical techniques in order to evaluate for patients with complications
consist of either performing bilaminar osteotomies such as persistent neck pain and diminished cervi-
and shifting the posterior elements backward or cal motion, which can manifest as canal restenosis
performing laminar osteotomy on one side and and loss of cervical lordotic alignment.
a b
Fig. 11.14 Laminoplasty. Axial CT image (a) shows ferent patient shows a right laminar hinge and bone graft
bilateral laminar osteotomies with posterior translation of (arrow) interposed in the left laminar open door, In addi-
the posterior elements, which are secured using a metal tion, there has been resection of the spinous process
prosthesis on the right side. Axial CT image (b) in a dif-
11.2.6 Vertebrectomy mechanical support (Fig. 11.16). Expandable

cage designs that can be adjusted to fit the
11.2.6.1 Discussion length of the surgical defect are also available
Vertebrectomy is sometimes necessary to treat (Fig. 11.17). Morselized bone graft material is
extensive spine, tumors, infections, or fracture- often packed inside the cage. The Harms cage
dislocations. Part (partial vertebrectomy) or is often used in combination with anterior or
all (total vertebrectomy) of a vertebra can be posterior fusion hardware, which yields fusion
removed. In particular, corpectomy is a specific rates of over 90%. Carbon fiber cage systems
type of partial vertebrectomy in which the ver- can also be used for anterior column reconstruc-
tebral body is partially or completely resected. tion following corpectomy, mainly in the setting
Extensive vertebrectomy operations are often of spine tumor and trauma surgery. Carbon fiber
performed in stages. For example, en bloc is a biocompatible material that can be used to
bone resection can be performed using a dia- make stackable cage systems. Except for the
mond threadwire saw (T-saw), osteotome, and/ central metallic rod, on radiographs and CT,
or Gigli saw. The threadwire is sometimes left the carbon fiber components are radiolucent,
in the surgical bed for staged operations, such while on MRI, the carbon fiber components are
that the device may sometimes be encountered of low signal intensity on T1 and T2 sequences
on interval imaging (Fig. 11.15). Subsequently, (Fig. 11.18). The role of imaging, particularly
the vertebra can be reconstructed using iliac with CT, is to assess the progression of fusion
crest, tibia, and fibula strut grafts or various and to evaluate for complications, such as graft
types of synthetic cages. Interbody cages, such or instrument displacement (Figs. 11.19 and
as the Harms cage, are interposed vertically 11.20). High-resolution CT with 3D renderings
between vertebral bodies after vertebral body is particularly useful for assessing the position
resection in order to promote fusion and provide and integrity of the hardware.
a b
Fig. 11.15 Staged total vertebrectomy using threadwire laminectomy and posterior fusion. The follow-up sagittal
saw and fibular bone graft reconstruction. Axial (a) and CT image (d) shows interval corpectomy with fibular
sagittal (b) CT images and the frontal radiograph (c) show grafting and removal of the wire
the wire encircling a diseased vertebral body following
c d
a b
Fig. 11.16 Harms cage. Sagittal (a) CT image shows a shows a cylindrical metal mesh cage and adjacent poste-
cage filled with bone graft (arrow). There is also anterior rior fusion hardware
fusion hardware. 3D CT image (b) in a different case
a b
Fig. 11.17 Expandable cage. Sagittal CT image demonstrates the telescoping components of the metallic expandable
cage (a). Photograph of an expandable cage (b)
a b
Fig. 11.18 Corpectomy with stackable carbon fiber Axial CT image (b) shows the low attenuation rectangular
reconstruction. Frontal (a) radiograph shows corpectomy stackable cages and constraining metallic rod. Axial
and fusion with stackable carbon fiber-reinforced cages T2-weighted MRI (c) shows the low signal intensity rect-
constrained by a central metallic rod (arrow). The cages angular carbon fiber cage
are otherwise radiolucent except for tiny metallic markers.
Fig. 11.19 Slippage of expandable cage. Sagittal

CT image shows complete dislocation of the spine
from the corpectomy cage with associated angular
kyphosis of the cervical spine and compromise of
the spinal canal contents
a b
Fig. 11.20 Dislocated bone grafts. Frontal radiograph such that the inferior end of the right graft and the superior
(a) and coronal CT image (b) show lateral displacement end of the left graft no longer contact the adjacent
of the bilateral fibular grafts out of the corpectomy defect endplates
11.2.7 Cordectomy or extramedullary tumors that invade the spinal

cord. Laminectomy, corpectomy, or vertebrec-
11.2.7.1 Discussion tomy can be performed in conjunction with cor-
Cordectomy involves resection of the spinal dectomy. Therefore, materials used to stabilize
cord. This unusual procedure is reserved for the spine, such as methyl methacrylate, can safely
selected patients with severe neurologic deficits extend into the spinal canal at the level of the cor-
and symptoms related to intramedullary tumors dectomy (Fig. 11.21).
Fig. 11.21 Cordectomy. The patient is status post chor-

doma excision with recurrence, which required resection
of the spinal cord and placement of posterior rods and
methyl methacrylate for spinal stabilization. Axial CT
image shows cement filling the spinal canal (*)
11.3 Spine Stabilization to a padded fiberglass or plastic thoracic cast by

and Fusion metal struts. The Gardner-Wells device consists of
two screws attached to both sides of the skull that
11.3.1 Halo and Traction Devices support the tongs to which traction is applied.
Both types of devices provide excellent long-term
11.3.1.1 Discussion cervical spine fixation. Pullout of the screws is a
A variety of surgically affixed devices are avail- rare, but potentially devastating complication. In
able for immobilization and traction of unstable addition to pullout, screw site infection or screw
cervical spine fractures and dislocations, including breaking through the inner cortex of the skull is a
halo vests and Gardner-Wells tongs (Figs. 11.22 rare complication. In general, devices composed
and 11.23). Halo vests comprise a metallic ring of aluminum or graphite-carbon composites and
secured to the skull via screws. The ring is attached plastic joints are MRI compatible.
Fig. 11.22 Halo vest. Scout image shows the device

secured to the skull and shoulder girdle
Fig. 11.23 Gardner-Wells device. Scout image shows
the traction device with bilateral scalp screw fixation
11.3.2 Bone Graft Materials matrix is combined with bone grafts, which has
attenuation intermediate between medullary and
11.3.2.1 Discussion cortical bone. Ceramics include calcium sulfate,
Several options are available for promoting bone hydroxyapatite, tricalcium phosphate, or a com-
fusion, including autologous, allograft, and syn- bination of hydroxyapatite and tricalcium phos-
thetic bone grafts. Autologous bone grafts are phate that are available in the form of pellets,
often harvested from the iliac crest, rib, or local pastes, or cement. These materials are denser
lamina, and spinous process (Fig. 11.24). than native bone. Composite materials such as
Alternatively, a trephine system can be used to moldable morsels contain mixtures of ceramic
obtain a core of cancellous bone from an adjacent and collagen or other demineralized bone matrix
vertebral body, which leaves a cylindrical defect components. The mineralized component (i.e.,
in the anterior portion of the vertebral body and calcium phosphate) provides compressive
pedicle (Fig. 11.25). Allografts are derived from strength and a substrate for bone formation, while
cadavers and are available as bone chips or cylin- the collagen contributes tensile strength and pro-
ders from fibula or rib and retain some bony motes hemostasis at the surgical site. On CT,
structure (Fig. 11.26). Ultimately, an uninter- such materials appear as grainy foci of heteroge-
rupted bony bridge should form across the verte- neous attenuation (Fig. 11.29).
bral bodies and facet joints as the bone graft Recombinant bone morphogenic protein
fusion matures (Fig. 11.27). (BMP) is often added to bone graft agents in
The main types of synthetic bone graft substi- order to promote fusion. This substance promotes
tutes that are used during spine surgery include bone resorption or osteolysis. Despite this find-
ceramics, demineralized bone matrix, and com- ing, fusion typically progresses and matures
posite materials. Demineralized bone matrix con- within 2 years. In fact, BMP expedites arthrode-
sists of non-collagenous proteins, bone growth sis. On imaging, BMP-induced osteolysis appears
factors, and collagen, which are intended to stim- as multiple cystic spaces in the endplate adjacent
ulate bone healing. These materials are radiolu- to the implant (Fig. 11.30). BMP is also known to
cent and difficult to visualize directly on imaging. form an excessive inflammatory response with
Demineralized bone matrix is available in pow- excessive fluid collections in the early
der form or as putty that can be used to fill voids postoperative period, sometimes even leading to
(Fig. 11.28). Sometimes demineralized bone undesired bone formation within the spinal canal.
a b
Fig. 11.24 Autologous bone graft harvested from the (encircled). Demineralized bone matrix was also applied.
iliac crest. Axial CT of the spine (a) shows bilateral corti- Axial CT at a lower level (b) shows the iliac donor site
cal and cancellous bone fragments with sharp edges packed with hemostatic agent (arrow)
Fig. 11.25 Local vertebral body bone harvest. Axial CT

image shows cylindrical defect in the anterior vertebral Fig. 11.27 Mature bone graft fusion. Coronal CT image
body (arrow) shows a solid fusion mass that bridges the left L4 and L5
vertebrae from transverse process to transverse process
(arrow)
Fig. 11.26 Allograft bone chips. Axial CT image shows

numerous cubes of cancellous cadaveric bone grafts
within an adjacent to the laminectomy site. Many of the
chips show a trabecular bone structure and contain air Fig. 11.28 Demineralized bone matrix. Sagittal CT
image shows amorphous hyperattenuating material filling
the space of partially collapsed vertebral bodies secondary
to prior osteomyelitis (arrow)
Fig. 11.29 Composite Mozaik moldable morsels.

Axial CT image shows the mixture of bone putty
and moldable morsels as numerous tiny
heterogeneously hyperattenuating foci (encircled)
spanning the posterior surgical defect adjacent to
the segmental instrumentation
a b
Fig. 11.30 Recombinant BMP-induced osteolysis. interbody fusion. Sagittal T2-weighted MRI (b) shows
Sagittal (a) CT image shows rounded lucencies (arrow) high-intensity foci (arrows) within the endplates adjacent
along the inferior endplate of the vertebral body above the to the interbody fusion material
11.3.3 Implantable Bone Stimulators 11.3.4 Odontoid Screw Fixation
11.3.3.1 Discussion 11.3.4.1 Discussion

Implantable (internal) bone stimulators are Anterior fixation of odontoid fractures consists of
devices that deliver electrical currents to promote securing the fracture fragment with one or two lag
bone growth and healing and to expedite fusion. or cortical screws depending on the diameter of
This device consists of electrodes that are posi- the dens. A lag screw is used in order to help
tioned in contact with the site of spinal fusion and reduce the fracture. Complications of this
a small power source that is implanted in the sub- procedure include hematomas, dysphagia, hoarse-
cutaneous tissues (Fig. 11.31). The role of imag- ness, and vascular, spinal cord, or nerve root inju-
ing is to confirm proper positioning of the ries. Radiographs and/or CT may be obtained for
electrodes and assess progression of bony fusion follow-up, especially in order to assess for union
or healing. (Fig. 11.32). The tip of the screw can often safely
project beyond the posterosuperior edge of the
dens by several millimeters. Other options for
treating odontoid fractures include posterior spinal
fusion or halo-vest immobilization.
Fig. 11.31 Bone stimulator. Lateral radiograph shows

the leads in contact with the fusion masses and the battery
pack (arrow) implanted in the subcutaneous tissues
Fig. 11.32 Odontoid screw fixation. Sagittal CT (a)

shows anterior fixation of the dens fracture via a single lag
screw. The dens fracture fragments are well aligned, but
remain unfused. Photograph of an odontoid lag screw (b)
11.3.5 Occipitocervical Fusion ity does not seem to correlate with the presence
or absence of radiographically evident bone
11.3.5.1 Discussion graft fusion. Sublaminar wires have the poten-
Indications for occipitocervical fusion include tial to unravel, resulting in recurrent malalign-
anterior and posterior bifid C1 arches with insta- ment and instability (Fig. 11.35) and generally
bility, absent occipital condyles, severe reducible provide less stability than screw constructs. In
basilar invagination, unstable dystopic os odon- addition, wire fracture can lacerate the spinal
toideum, unilateral atlas assimilation, traumatic cord. The occipital screws can sometimes pene-
occipitocervical dislocation, complex craniover- trate the inner table of the occipital bone
tebral junction fractures of C1 and C2, transoral (Fig. 11.36), which may not necessarily result in
craniovertebral junction decompression, cranial cerebellar injury, especially if it is only by a
settling in Down’s syndrome, tumors, and inflam- small extent. Transarticular screw fixation of the
matory disease such as Grisel’s syndrome. cervical spine can encroach upon the transverse
A variety of internal fixation methods have foramina and potentially injure the vertebral
been developed for posterior craniocervical arteries or even impinge upon the internal
junction fusion including sublaminar wiring carotid arteries (Fig. 11.37). The incidence of
(Fig. 11.33) and occipital rods and plates nonunion or loosening is about 7% for occipito-
(Fig. 11.34). Bone grafts are often added along- cervical fusion and atlantoaxial fusion, which
side the posterior elements in order to promote appears as lucency around the hardware on CT
bony fusion. Interestingly, the degree of stabil- (Fig. 11.38).
a b
Fig. 11.33 Atlantoaxial fusion with sublaminar wiring. strate posterior atlantoaxial fixation with bilateral cables
The patient has a history of an unstable dens fracture. that pass into the spinal canal and around iliac crest bone
Lateral radiograph (a) and axial CT image (b) demon- grafts applied posterior to the C1 and C2 arches
a b
Fig. 11.34 Occipitocervical fusion with rods and screws. and screws and to the upper cervical spine via lateral mass
Sagittal CT image (a) shows the curvilinear posterior rod screws. Photograph of an occipital plate (b)
(arrow) attached to the occipital bone via plate (arrow)
a b
Fig. 11.35 Unraveled sublaminar wire. The patient has a C2 with sublaminar wires and application of bone graft.
history of unstable os odontoideum. Preoperative sagittal There is resulting decreased C1–C2 interspinous distance
(a) CT image shows a dystopic os odontoideum angled and angulation of the os odontoideum. Subsequent sagit-
anteriorly and a widened C1–C2 interspinous space tal CT image (c) shows interval widening of the C1–C2
(bracket). Initial postoperative sagittal CT image (b) interspinous distance and angulation of the os odontoi-
shows interval fixation of the posterior elements of C1 and deum similar to the configuration before surgery
c a
b
Fig. 11.37 Vascular compromise by screw malposition.

Fig. 11.36 Occipital screw intracranial penetration. Axial CT image (a) shows a right lateral mass screw
Sagittal CT image shows penetration of the inner table within the right foramen transversarium (arrow). Coronal
with intracranial extension of a lateral occipital plate CTA image in another patient (b) shows impingement of
screw (arrow) the left internal carotid artery (encircled)
a b
Fig. 11.38 Hardware loosening. Sagittal CT image (a) s urrounding multiple lateral mass screws (arrows), which
shows lucency surrounded the hardware in the occipital have begun to pull out
bone (arrow). Sagittal CT image (b) shows lucencies
11.3.6 Anterior Cervical Fusion Complications of anterior cervical fusion

include hardware infection, dysphagia, hema-
11.3.6.1 Discussion toma, esophageal perforation, subsidence, spinal
Anterior cervical plates are commonly used for cord injury in the cervical spine, and bowel, or
fusion to treat degenerative conditions, as well as vascular injury in the lumbar spine. A fluid col-
fractures, infections, and tumors. The hardware lection and foci of gas can be identified in the
most commonly spans two or three vertebral prevertebral space on CT with hardware infection
body levels, but can be as many as five vertebral (Fig. 11.41). MRI is used to evaluate for an asso-
bodies. The plates are affixed to the vertebral ciated epidural abscess.
bodies via screws (Fig. 11.39). The screws should Subsidence of the hardware or graft material
not transgress the adjacent disc space. The plates is a chronic process in which the materials pene-
and screws are most often metallic, although trate into the adjacent vertebral bodies or disc
some biodegradable devices have been devel- spaces. This can lead to postoperative deformity
oped. Another technique for anterior cervical and sclerosis, which can be assessed on CT
fusion is the use of interbody devices without the (Fig. 11.42).
use of plate (stand-alone). These devices are typi- Cervical spinal cord injury can rarely occur
cally composed of polyether ether ketone (PEEK) during screw placement, potentially creating a
and are fixed to the vertebral body either with two transecting spinal cord injury (Fig. 11.43).
or three screws or fins (Fig. 11.40). For example, Dysphagia and dysphonia are common following
Zero P is a Synthes device used as a stand-alone anterior cervical fusion due to injury to the pha-
implant in cervical interbody fusion and incorpo- ryngeal plexus and recurrent laryngeal nerve. CT
rates both the interbody cage and fixation plate. can be used to assess the neck soft tissue in such
The device has a low profile anteriorly, resulting cases, which may reveal supraglottic edema
in decreased soft tissue and esophageal irritation. (Fig. 11.44). Otolaryngology consultation should
Zero P and all similar devices are designed to be obtained for patients with postoperative dys-
reduce adjacent level ossification, since the plate phagia or dysphonia, particularly if that persists
does not irritate the adjacent disc. longer than 1–2 months.
a b
Fig. 11.39 Anterior cervical discectomy and fusion vertebral bodies via screws. Anterior discectomy and
(ACDF). Axial (a), sagittal (b), and 3D (c) CT images placement of intervertebral allografts was also performed
show an anterior cervical plate secured flush against the (arrows)
Fig. 11.40 Stand-alone anterior cervical discectomy and

fusion. Lateral radiograph shows the LDR ROI-C cage
Fig. 11.39 (continued) and fins C6-7 (arrow)
a b
Fig. 11.41 Infection. Axial CT image (a) demonstrates a post-contrast T1-weighted MRI (b) shows extensive
fluid collection containing foci of gas anterior to the ante- enhancement in the prevertebral space as well as exten-
rior cervical spine hardware (arrow). Axial fat-suppressed sion into the anterior epidural space (arrow)
Fig. 11.42 Bone graft subsidence and retropulsion.

Sagittal CT image shows the bone graft dowel (arrow)
protruding into the spinal canal and adjacent vertebral
bodies Fig. 11.44 Supraglottic swelling after anterior cervical
fusion. The patient experiences difficulty breathing after
cervical spine surgery. Sagittal CT image shows multiple
level cervical anterior fusion with surgical hardware and
swelling of the supraglottic soft tissues (arrow)
Fig. 11.43 Iatrogenic spinal cord transection from ante-

rior cervical fusion. Axial CT image of the cervical spine
shows a cylindrical bone fragment (arrow) within the cen-
tral spinal canal. There is anterior fusion hardware and
soft tissue air from the recent surgery (Courtesy of
Richard White, MD)
11.3.7 Anterior Approach of the thoracolumbar vertebral column in the set-

Thoracolumbar Spine ting of burst fracture stabilization or corpectomy
Stabilization Devices via anterior approaches. The Kaneda device con-
sists of a rod and screws with additional staples,
11.3.7.1 Discussion which reinforce the purchase of the screws in the
Anterior surgical approach short-segment stabili- vertebrae, resulting in robust fixation (Fig. 11.45).
zation systems, such as the Kaneda device (DePuy The Vantage plate features several slots for select-
Spine, Raynham, Mass) and the Vantage plate ing the optimal level of the screws that are secured
(Medtronic, Sofamor Danek, Memphis TN), are to adjacent vertebral bodies (Fig. 11.46). The
adjustable devices that can provide rigid fixation device is inserted by using an anterior approach.
a b
Fig. 11.45 Kaneda device. Axial (a) and coronal (b) CT images show the rod and screw system positioned along the
left lateral aspect of the vertebrae. An expandable cage is also present in the intervening space
a b
Fig. 11.46 Adjustable plate system. Lateral thoracic spine radiograph (a) and coronal CT image (b) show the adjust-
able plate (arrow) spanning the corpectomy site, where there is a tibial structural allograft
11.3.8 Posterior Fusion cava, if they are too long and exit the anterior ver-
tebral body. Although transdiscal screws are
11.3.8.1 Discussion sometimes used for fixation in scoliosis surgery,
Most thoracic and lumbar spine fixation is per- penetration into the disc space is generally
formed via a posterior approach, most commonly avoided. Another option for securing rods is
using rods and pedicle screws. Pedicle screws through lateral mass screws, which are situated
attach posteriorly to rods or plates via clamps or between the superior and inferior articular pro-
bolts and have shallow cancellous threads that cesses, thereby lowering the likelihood of the
pass through the pedicle and into the vertebral types of malpositioning associated with pedicle
body. The screw should enter 50–80% of the ver- screws (Fig. 11.50).
tebral body and be parallel to the endplates with Instead of screws, rods can also be secured to
at least 2 mm of separation. The screws can pro- the vertebrae via sublaminar wires or cables
duce considerable beam-hardening artifacts on (Fig. 11.51). Sublaminar wires or cables pass
CT, which can be minimized through the use of around the lamina and rods and are twisted or
metal artifact reduction software (Fig. 11.47). On clamped at their ends. Alternatively, laminar or
MRI, the pedicle screws can produce variable sublaminar hooks can be used for compression or
degrees of metal susceptibility artifact that can distraction. Hooks that pass below the lamina are
obscure adjacent structures, which is more pro- termed up-going, while those that pass above the
nounced at higher magnetic field strength lamina are termed down-going (Fig. 11.52).
(Fig. 11.48). Imaging via CT is sometimes per- These two configurations are usually applied
formed in order to assess whether the screws are simultaneously for optimal stability. The hooks
malpositioned (Fig. 11.49). Medial malposition- are connected to the rods via screws, bolts, or
ing is a potentially devastating complication that washers. Facet screw fixation is an alternative to
can result in spinal cord or nerve injury. Laterally pedicle screw fixation whereby the articular fac-
malpositioned screws can injure exiting nerve ets are fused. The screws are not attached to rods
roots. Pedicle screws can also potentially cause but may be used in conjunction with interbody
vascular injury, such as the aorta or inferior vena fusion or anterior plating (Fig. 11.53).
a b
Fig. 11.47 Metal artifact reduction software. Axial CT image with metal artifact reduction software (b) shows
image (a) shows extensive metal artifact associated with much less artifact
the surgical hardware. The corresponding axial CT
a b
Fig. 11.48 Spine hardware artifacts at 3 T versus the pedicle screws, which obscures the surrounding anat-
1.5 T. Sagittal T2-weighted MRI performed on a 3 T scan- omy. Sagittal T2-weighted MRI performed on a 1.5 T
ner (a) shows extensive susceptibility artifact related to scanner (b) shows much less artifact from the hardware
a b
c d
Fig. 11.49 Malpositioned screws. Coronal CT image (a) racic pedicle screw into the spinal canal (arrow), resulting
shows a screw that breaches the superior endplate and in paraplegia. Axial CT images (c and d) in another patient
enters the intervertebral disc space. Axial CT image (b) in show screws impinging upon the aorta, which contains an
another patient shows medial malposition of the right tho- endograft and impinging upon the trachea
a b
Fig. 11.50 Lateral mass screws and rods. Frontal radiograph (a) and axial CT image (b) show bilateral screws travers-
ing the lateral mass. Unlike transpedicular screws, lateral mass screws are directed laterally
Fig. 11.51 Wire fixation. 3D CT image shows sublaminar wires

attached to the rods
Fig. 11.52 Pedicle hooks. Sagittal CT image shows

upgoing and down-going hooks secured to the laminae
and attached to a rod
Fig. 11.53 Facet screws. Frontal radiograph (a) and

axial CT image (b) demonstrate bilateral L5–S1 facet
screws. Anterior fusion was also performed
11.3.9 Scoliosis Rods are placed, the rods can provide either compres-
sion or distraction. Perhaps the most common
11.3.9.1 Discussion usage of these rods is for treatment of severe
A variety of rods are used for posterior spinal scoliosis, which can sometimes be partially

fixation in the treatment of scoliosis, including corrected.
Harrington, Knodt, and Luque (Figs. 11.54, Complications include rod fracture or disloca-
11.55, and 11.56). In contrast to threaded Knodt tion and screw pullout, which can be predisposed
rods, Harrington rods feature flanged ends, which by the high torque inherent to the length of the
can attach to laminar hooks. Harrington rods are hardware (Figs. 11.57, 11.58, and 11.59). The
usually paired and interconnected by segmental thoracolumbar fixation hardware may also lead
wires for added stability. Luque rods are spino- to “flat-back” syndrome, in which there is loss of
pelvic fixation devices that can be used to treat lumbar lordosis (Fig. 11.60). Scout and 3D CT
scoliosis, among other applications. The appara- reconstructions are particularly helpful for evalu-
tus has a characteristic L shape in which the infe- ating mechanical complications, while MRI
rior angled portion can be affixed to the ilium. might be more useful for assessing spinal canal
Depending on the direction in which the hooks involvement.
Fig. 11.55 Knodt rods. Frontal radiograph shows two

rods with threaded ends
Fig. 11.54 Harrington rod. Frontal radiograph shows a

metallic rod with flanged end (arrow) spanning the thora-
columbar spine in a patient with scoliosis
Fig. 11.56 Luque rods. Frontal radiograph shows instru-

mentation with pelvic fixation using the Galveston tech-
nique (arrow)
Fig. 11.58 Rod dislocation. Lateral scout images show

posterior displacement of the inferior end of the
Harrington rod (encircled) with separation from the hook
Fig. 11.57 Rod fracture. 3D CT image shows a dis-

placed fracture of one of the Harrington rods (arrow)
Fig. 11.59 Screw pullout. Sagittal CT image shows mul-

tiple screws that are posteriorly displaced along with the
inferior end of the scoliosis rod
Fig. 11.60 Flat-back syndrome. The patient presents

with chronic low back pain and poor posture. Sagittal CT
image demonstrates straightening vertebral alignment
with loss of lumbar lordosis along the same levels as the
rods
11.3.10 Vertebral Stapling inserted into the lateral aspects of the vertebral
bodies across the disc spaces unilateral to the
11.3.10.1 Discussion convex side of the scoliosis (Fig. 11.61). A tho-
Vertebral body stapling is a minimally inva- racoscopic approach can be used for thoracic
sive, fusionless alternative to reduce curvature curves and a mini-open retroperitoneal
progression in patients with mild idiopathic approach for lumbar curves. Initial success
scoliosis. Vertebral staples are composed of rates are high and with few associated compli-
shape memory alloys that can be custom fit to cations, although long-term follow-up is not
the size of the vertebral body. The staples are yet available.
a b
Fig. 11.61 Vertebral staples. Frontal (a) and lateral (b) radiographs show the C-shaped staples positioned in multiple
contiguous vertebral bodies along the convex side of the thoracic scoliosis
11.3.11 Vertical Expandable devices are typically implanted at the time of wedge
Prosthetic Titanium Rib thoracostomy and consist of an adjustable metal rod
(VEPTR) that is interposed vertically between ribs on the con-
cave side of the scoliosis for distraction (Fig. 11.62).
11.3.11.1 Discussion Most patients with VEPTR maintain near-normal
VEPTR is used to gradually correct chest wall thoracic spine growth rates and satisfactory lung
deformity and scoliosis in selected pediatric volumes. Complications include device migration,
patients, with repeated lengthening sessions. The infection, and brachial plexus injury.
a b
Fig. 11.62 Vertical expandable prosthetic titanium rib. radiographs show two metallic devices interposed
The patient is a child with a history of severe scoliosis and between the right ribs
associated chest wall deformity. Frontal (a) and lateral (b)
11.3.12 Interbody Fusion More recent interbody fusion devices are mainly
composed of polyether ether ketone (PEEK) or bio-
11.3.12.1 Discussion compatible high-density carbon fiber. These materi-
The goal of lumbar interbody fusion with pros- als are radiolucent, which facilitates visualization of
thetic devices is to provide stability while pro- the bone graft-vertebral body endplate interface.
moting bony ingrowth. Many materials and The devices also contain press-fit titanium markers
devices have been used for this purpose, includ- in order to demarcate the boundaries of the device
ing bone threaded bone graft dowels or femoral on radiographs. Many designs are in use, but gener-
rings, metal cages, and polymer cages. Femoral ally are rectangular with grooves in order to pro-
ring grafts are cylindrically shaped and inserted mote vertebral body attachment. There are a variety
into the intervertebral disc space via anterior of approaches that can be used for interbody fusion
lumbar interbody fusion, posterior lumbar inter- (Figs. 11.66, 11.67, 11.68, 11.69, 11.70, and 11.71
body fusion, or transforaminal lumbar interbody and Table 11.2).
fusion approach (Fig. 11.63). A major disadvan- Imaging can be used to assess the position of
tage of such allograft device is the risk of dis- the implants, which should be located at least
ease transmission. Wide varieties of metal cages 2 mm anterior to the posterior wall of the verte-
have been and continue to be developed. The bral body. Another role of imaging following
first-generation Bagby and Kulich (BAK) and interbody fusion surgery is to assess fusion versus
second- generation Ray threaded fusion cages pseudarthrosis. Radiographs with lateral flexion
are cylindrical, hollow, porous, threaded, tita- and extension views can be used for this purpose,
nium alloy cages that can be screwed into posi- although the accuracy is highly dependent upon
tion in the intervertebral disc space (Fig. 11.64). precise positioning and the type of implant.
The more recent third-generation LT-CAGE has Rather, CT is the modality of choice for evaluat-
been widely used in North America and has a ing interbody fusion, although the streak artifact
trapezoidal, tapered configuration that provides from the early stainless devices can obscure adja-
increased surface area for bone growth and cent bone formation. Early bone healing can often
facilitates restoration of lumbar lordosis be appreciated at 3 months and is usually nearly
(Fig. 11.65). complete at 6 months after surgery.
a b
Fig. 11.63 Femoral ring allograft. Axial (a) and coronal (b) CT images show a cylindrical bone fragment inserted into
the intervertebral disc space (arrows)
a b
Fig. 11.64 Threaded cage. Sagittal (a) and coronal (b) CT images show two cylindrical hollow cages screwed into the
intervertebral disc space
a b
Fig. 11.65 Tapered LT-CAGE. Lateral radiograph (a) and sagittal CT image (b) show two metallic cages fitted into the
intervertebral disc spaces. Mature bony fusion is most apparent on the CT
a b
Fig. 11.66 PLIF. Axial (a) and sagittal CT (b) images intervertebral disc space. Laminectomy and posterior
show the radiolucent PEEK cage with metallic markers fusion hardware is also present
and filled with bone graft (arrows) in the midline of the
a b
Fig. 11.67 TLIF. Axial CT (a) and axial T1-weighted (b) show the PEEK cage (arrows) positioned obliquely in the
intervertebral space at nearly a 45° angle with respect to the sagittal plane
a b
Fig. 11.68 XLIF. Axial (a) and coronal (b) CT images material within the device. Axial T1-weighted (c) MRI
show the metallic markers of the XLIF device, which is shows the XLIF device as low signal intensity with a “fig-
positioned in the intervertebral space. There is bone graft ure of 8” shape
Fig. 11.69 ALIF. Lateral radiograph shows a Synfix

device implanted in the L5–S1 anterior disc space (arrow).
Posterior stabilization hardware is also present
a b
Fig. 11.70 Stalif. Frontal radiograph (a) and sagittal CT enter the anterior vertebrae above and below. Note the
image (b) show that the device composed of both radiolu- absence of additional hardware. As such, the device
cent and metallic parts, including titanium screws that “stands alone”
Fig. 11.71 Transsacral fusion. Sagittal CT image shows

the vertically oriented axial lumbar interbody fusion hard-
ware and mature bony bridging across the L5–S1 disc
space
Table 11.2 Types of interbody fusion

Photographs of various types of
Device Description interbody fusion devices
PLIF (posterior lumbar Consists of a posterior midline approach to the
interbody fusion) disc space. The interbody cage is inserted into
the intervertebral disc space via a laminectomy
or hemilaminectomy defect. As a result, the
long axis of the device is typically positioned
nearly parallel to the sagittal plane. Concurrent
facetectomy is often performed
TLIF (transforaminal lumbar Modification of the PLIF procedure, in which
interbody fusion) the interbody fusion prosthesis is more lateral.
The long axis of the cage tends to be positioned
obliquely (approximately 45°) with respect to
the sagittal plane. This procedure can be
performed via a midline approach as a PLIF or
a minimally invasive approach with two
paramedian incisions. Full facetectomy
(unilateral or bilateral) is also performed.
Fixed-size or expandable cages can be inserted
into the disc space
XLIF (extreme lateral Proprietary PEEK implant that is inserted
interbody fusion; NuVasive, laterally into the intervertebral space through a
Inc., San Diego, CA) minimally invasive retroperitoneal approach.
These implants have a characteristic of long,
rectangular shape, designed to maximize
surface area on which the epiphyseal ring can
rest. There are also slots for packing bone graft.
Other vendors endorse this approach and have
different variations on the lateral cage
OLIF (oblique lumbar A variant on the XLIF where the lateral spine is
interbody fusion; Medtronic, approached obliquely instead of orthogonally.
Minneapolis, MN) The cages are placed in a similar fashion to the
XLIF technique
ALIF (anterior lumbar Consists of anterior discectomy and insertion
interbody fusion) of the interbody prosthesis via a retroperitoneal
approach. The procedure can be performed
with or without posterior stabilization.
However, the addition of pedicle screw fixation
with ALIF results in a significant increase in
the rate of interbody fusion
Stalif (stand-alone lumbar Can absorb energy, handle the normal weight
interbody fusion) of the body, and minimize stress on adjacent
levels. Thus, the devices do not require
additional fusion procedures, such as posterior
pedicle screw and rod fixation
AxiaLif (transsacral fusion) Can be performed using the AxiaLif® system Photograph of AxiaLif device.
(TranS1, Inc., Wilmington, NC). Initially, a (Courtesy of Quandary Medical)
series of guide pins and dilator tubes are
inserted under fluoroscopic guidance and used
to obtain access to the L5–S1 disc space.
Subsequently, a discectomy is performed
percutaneously. Finally, a threaded titanium pin C
L
is placed across the disc space. This procedure
is often combined with posterior fixation with
facet or pedicle screws introduced through a
minimally invasive technique
11.4 Dynamic Stabilization for these complications in order to exclude

Devices of the Spine impingement upon the adjacent great vessels.
Subsidence of total disc prostheses into the
11.4.1 Total Disc Replacement adjacent vertebral body occurs in about 3% of
cases in the lumbar spine and can be asymptom-
11.4.1.1 Discussion atic or cause recurrence of pain. Risk factors
Total disc replacement is an option for treating include osteopenia, an oblique approach versus
degenerative disc disease, in which motion at the an anterior approach, removal of too much of the
operated level is preserved. In theory, this tech- endplate, and the use of an undersized prosthesis.
nique results in less load transfer to adjacent lev- Total disc subsidence is most readily identified
els compared with fusion. Several types of disc on lateral radiographs and sagittal or coronal CT
replacement are available, including one-piece reconstructions (Fig. 11.77).
implants and implants with single- or double- The frequency of heterotopic ossification after
gliding articulations with metal-on-metal or total disc replacement ranges from 1.7% to 7.7%.
metal-on-polymer bearing surfaces (Figs. 11.72, Heterotopic ossification along the lateral aspect
11.73, and 11.74). For example, the Charite® of the device often leads to ankylosis and limited
device is a three-part device consisting of two range of motion, while the heterotopic bone ante-
cobalt-chromium-molybdenum (CoCrMo) alloy rior to the device is usually of no significance.
endplates and a radiolucent ultra-high-molecular- Annular ossification can also occur, and this actu-
weight polyethylene core. The radiolucent core ally decreases the risk of device dislocation. On
is delineated by a small radiopaque metal wire. imaging, partial or complete bone formation
There are small “teeth” along the device end- across the disc space can be identified (Fig. 11.78).
plates in an attempt to anchor the device in the Vertebral body fracture has been reported in
vertebral endplates and limit migration. The end- less than 1% of cases with the Charite device and
plates are coated with porous plasma-sprayed tends to involve the endplate (Fig. 11.79). In con-
titanium and with calcium phosphate to promote trast, devices with a keel, such as ProDisc, are
bony ingrowth. ProDisc is also a three-part disc prone to the characteristic vertical split fractures.
arthroplasty device with two metallic endplates Short vertebral body heights predispose to frac-
and a radiolucent inlay that snaps onto the lower ture with these models. Prosthesis-associated
endplate to prevent extrusion. The device is fractures should be evaluated with CT to assess
secured in the adjacent vertebral bodies by for spinal canal stenosis and associated findings,
ridged keels along both of the endplates such as device migration.
(Fig. 11.75). Finally, it is important to consider disease at
Migration of the disc prosthesis is not uncom- adjacent levels when patients present with pain fol-
mon and usually occurs in the anterior direction lowing total disc replacement. Adjacent-level disc
(Fig. 11.76). Oversizing and positioning the pros- degeneration is perhaps the most common explana-
thesis too far anteriorly in the disc space are risk tion in such situations. This outcome may result
factors for migration. Extrusion of the polyethyl- from increased stress on, or hypermobility of, adja-
ene inlay in the Charite device is a similar com- cent segments. If nothing is apparent, MRI should
plication and can occur if the wire surrounding be performed to evaluate the discs, although sus-
the core fractures in three-component prostheses. ceptibility effects from the hardware can degrade
It is important to obtain cross-sectional imaging detail of the adjacent levels as well (Fig. 11.80).
a b
c d
Fig. 11.72 Prestige cervical spine total disc prosthesis. coronal (d) CT images show the device positioned within
Flexion (a) and extension (b) views of the cervical spine the disc space, secured by two rows of corrugated keels
show the range of motion of the device. Sagittal (c) and
a b
Fig. 11.73 Advent cervical spine total disc prosthesis. Frontal (a) and lateral (b) radiographs show the total disc
replacement prosthesis in the lower cervical spine
Fig. 11.74 Charite lumbar spine total disc prosthesis.

Lateral radiograph shows the components, which com-
prises metallic endplates and a radiolucent polyethylene
core and metallic wire ring (arrow)
a b
Fig. 11.75 ProDisc-L total disc prosthesis. Lateral view the endplates. Photograph of ProDisc-L (b) (Courtesy of
of the lumbar spine (a) demonstrates proper positioning of Synthes, West Chester, PA)
ProDisc-L, which features serrated keels perpendicular to
a b
Fig. 11.76 Total disc prosthesis anterior migration. radiograph obtained at 4 postoperative months (b) shows
Initial postoperative lateral radiograph (a) shows satisfac- interval anterior migration of the C3–C4 device (arrow)
tory positioning of the C3–C4 total disc prosthesis. Lateral
a b
Fig. 11.77 Total disc prosthesis subsidence. Initial post- follow-up imaging at 6 weeks (b) shows that the superior
operative lateral radiograph (a) shows satisfactory posi- endplate of the C5–C6 device has subsided into the infe-
tioning of the total disc prosthesis at C5–C6. Routine rior endplate of C5 (arrow)
Fig. 11.78 Total disc prosthesis with heterotopic ossifi-

cation and ankylosis. Sagittal CT image shows bone Fig. 11.79 Total disc replacement vertebral fracture. The
(arrow) spanning the disc space at the level of the patient presented to the emergency department with
prosthesis severe back pain. The patient underwent implantation of
Charite® at L5–S1 about 6 months earlier. Sagittal CT
image shows a small fracture involving the posterior-
inferior corner of the L5 vertebral body (arrow)
a b
Fig. 11.80 Adjacent-level disc herniation after total disc the device (*). However, axial sagittal T2-weighted MR
replacement. The patient presented approximately 1 year image (b) shows a central and right subarticular recess
after implantation of Charite® at the L5–S1 disc space disc extrusion resulting in right L5 nerve root compres-
level with persistent back pain. Sagittal CT image (a) sion (arrow) despite the susceptibility artifact from the
shows degenerative disc disease at L4–L5 with vacuum hardware. This was new from an MRI of the lumbar spine
disc phenomenon. The CT is otherwise limited at the level obtained 6 months earlier
of the prosthesis due to the beam-hardening artifact from
11.4.2 Nucleus Pulposus hydrogel or nonhydrogel materials and pre-

Replacement formed or injectable. The mechanical nuclei can
be either one- or two-piece.
11.4.2.1 Discussion The NUBAC is a mechanical two-piece
Nucleus pulposus (partial disc) replacement sur- nucleus pulposus replacement device that is com-
gery is a minimally invasive technique that is posed of two endplates of PEEK-OPTIMA with
indicated for younger patients with persistent an inner ball-and-socket articulation. The large
disc herniation and prior discectomy. The two contact area results in low subsidence risk. The
main types of nucleus replacement devices device is radiolucent because of PEEK (polyether
include elastomeric and mechanical nuclei. ether ketone), but has a characteristic of radi-
Elastomeric nuclei can be composed either of opaque makers (Fig. 11.81).
a b
c d
Fig. 11.81 NUBAC. Frontal radiograph (a) shows three radiolucent. Axial (b) and coronal (c) CT MIP images
radiopaque markers from the nucleus pulposus in the L4– show the device centered within the disc space. Photograph
L5 disc space (encircled). The remainder of the device is of NUBAC (d)
11.4.3 Posterior Dynamic The X-Stop has an H-shaped configuration

Stabilization Devices consisting of two metal plates positioned lateral
to the spinous processes (Fig. 11.83). The inter-
11.4.3.1 Discussion spinous ligament is conserved in order for this
Interspinous spacers are designed for minimally device to be effective.
invasive treatment of neurogenic claudication. The DIAM (device for intervertebral assisted
In this condition, symptoms like radicular pain, motion) spinal stabilization system consists of a
sensation disturbance, and loss of strength in the silicone core covered by a polyester sleeve. Three
legs are relieved with flexion, presumably by mesh bands hold the core in place. Two of the
decreasing epidural pressure and increasing the bands encircle the adjacent spinous processes,
cross-sectional area of the spinal canal. The while a third encases the supraspinous ligament.
devices are typically placed into the interspi- The silicone device and bands are radiolucent,
nous space at the affected level. The implanta- but radiopaque markers are placed along the
tion is less invasive than spinal fusion superior-lateral aspect of the device (Fig. 11.84).
procedures, leaves the ALL and PLL intact, and As with other interspinous devices, loss of cor-
does not preclude removal and additional spinal rection ensues over time, although this does not
surgery. appear to affect clinical outcome.
Various designs for interspinous spacers are The coflex is a saddle-shaped device composed
commercially available, including the Isobar, of titanium that requires resection of the interspi-
X-Stop, DIAM, and coflex, among others. nous and supraspinous ligaments (Fig. 11.85). The
The Isobar incorporates radiopaque metallic wings are crimped onto the adjacent spinous pro-
posterior pedicle screws with limited motion processes. This device is inserted in conjunction with
vided by either a mobile screw head or mobile the central laminectomy.
rods (Fig. 11.82). The mobile portion of this par- Reported complications specific to interspi-
ticular device consists of a stack of metal rings nous prosthesis implantation include overcorrec-
that allow for flexion and extension and a damp- tion, spinous process fractures (Fig. 11.86), and
ener that allows for limited axial loading. The device dislocation (Fig. 11.87). These complica-
dampener and rings are contained in a bell- tions are not very common and may be predis-
shaped structure on the rod. posed by underlying anatomic variations.
Fig. 11.82 Isobar. Frontal scout image (a) shows bilat-

eral Isobar rods with mobile joints (arrows). Photograph
of the Isobar (b) (Courtesy of Alphatec Spine, Carlsbad,
CA, USA)
a b
Fig. 11.83 X-Stop. Frontal radiograph (a) shows an nous processes. Photograph X-Stop (b) (Courtesy of
X-Stop device in position L4–L5, which appears as Medtronic Sofamor Danek USA)
H-shaped metallic hardware interposed between the spi-
Fig. 11.84 DIAM. Coronal CT image (a) shows the

DIAM interspinous spacer device with bilateral high
attenuation markers on the sides. Photograph of the DIAM
device (b) (Courtesy of Medtronic Sofamor Danek USA)
a b
c d
Fig. 11.85 Coflex. Frontal (a) radiograph and coronal (b) and sagittal (c) CT images show a coflex device positioned
in the interspinous space. Photograph of Coflex (d) (Courtesy of Paradigm Spine, New York, NY)
Fig. 11.86 Periprosthetic fracture. Sagittal CT image

shows lucency (arrow) in the spinous process to which the Fig. 11.87 Dislocated device. Lateral radiograph shows
interspinous prosthesis is attached. The bones are dif- disengagement of the device from the interspinous space
fusely osteopenic and there is anterolisthesis at the oper- into the soft tissues posterior to the spinous processes
ated level
11.4.4 Dynamic Facet Replacement radiolucent, compressible polycarbonate ure-

thane. This polycarbonate acts as a shock
11.4.4.1 Discussion absorber and allows for motion between the end-
Facet replacement devices have been created in plates, providing rotation, bending, flexion, and
an attempt to replace only the diseased elements extension to the patient. The device is held in
in patients with facet arthropathy and spinal place by pedicle screws. On imaging, the screws
stenosis while maintaining normal or near-nor- and plates are radiopaque, and the central poly-
mal biomechanics of the spine. The total poste- carbonate urethane layer is radiolucent
rior facet replacement and dynamic motion (Fig. 11.88). Other devices used for facet replace-
segment stabilization system (TOPS) includes ment include TFAS (Total Facet Arthroplasty
two titanium endplates on either side of a layer of System) and Zyre.
a b
Fig. 11.88 Dynamic facet replacement device. Frontal (a) and lateral (b) radiographs show total posterior facet
replacement and dynamic motion segment stabilization system at L4–L5
11.4.5 Dynamic Rods pedicle screws at each treated level. The screws
at adjacent levels are connected by rods com-
11.4.5.1 Discussion prised of radiolucent polyethylene terephthalate
Dynamic posterior stabilization with pedicle fix- cord surrounded by a polycarbonate urethane
ation, such as Dynesys, consists of a semirigid spacer, which appears as a two concentric rings,
fixation system that allows minimal movement slightly more hyperattenuating centrally
between two segmental pedicle screws compared (Fig. 11.89). Complications include screw loos-
to a rigid metal rod and is used to treat lumbar ening, screw breakage, and degeneration in the
spinal stenosis and degenerative spondylosis. adjacent levels in up to approximately 50% of
Dynesys comprises and employs two titanium cases.
a b
Fig. 11.89 Dynesys. Frontal (a) and lateral (b) radio- rounding soft tissues, but slightly higher attenuation cen-
graphs show bilateral metallic pedicle screws at L3–L5, trally, corresponding to the polyethylene terephthalate
which are secured to radiolucent rods. Axial (c) and sagit- cord. Photograph of Dynesys Dynamic Stabilization
tal (d) CT myelogram images show the bilateral rods System (e) (Courtesy of Zimmer Spine, Minneapolis,
(arrows), which are nearly iso-attenuating to the sur- MN)
c d
Spacer:
Surrounds the
cord between
the Dynesys
Screw: screws; Cord:
Anchors the limits spinal Connects the
system to the extension Dynesys screws;
spine through limits spinal
the pedicles flexion
11.5 F
ailed Back Surgery uating patients with FBSS. In particular, a com-
Syndrome and Related Spine prehensive and systematic assessment of the
Surgery Complications postoperative spine includes a review of the neu-
ral and vascular structures, including the neural
11.5.1 Overview foramina, thecal sac, spinal cord and cauda
equina, hardware, and adjacent structures such as
Failed back surgery syndrome (FBSS) is a clini- the major abdominal vessels, psoas musculature,
cal entity that describes the persistence of lumbo- posterior mediastinum, and prevertebral soft tis-
sacral pain following surgical intervention. sues. Some of the causes of FBSS and related
Etiologies include structural abnormalities in the complications of spine surgery in general that can
back, psychosocial influences, or a combination be identified on imaging are summarized in
of these. Imaging plays an important role in eval- Fig. 11.90 and in the following sections.
Fig. 11.90 Schematic
of some of the potential
causes of failed back
surgery
11.5.2 Hardware Malpositioning Postoperative spinal hardware displacement can

and Migration be a significant complications that can produce
pain and new neurological symptoms. Retropulsion
11.5.2.1 Discussion of interbody fusion devices and grafts most com-
The incidence of malpositioned pedicle screws monly occurs at L5–S1 and is associated with a
ranges from 4% to 16%. Medial malpositioning wide disc space and multilevel fusion surgery.
of the screw can result in spinal cord or nerve However, these devices can also become displaced
root injury, while screws that extend too far anteriorly, especially if there has been a disruption
beyond the vertebral body can injure the great of the anterior longitudinal ligament. Radiographs
vessels (Figs. 11.49 and 11.91). However, clin- or CT can often adequately demonstrate the dis-
ically significant sequelae of screw malposi- placement of these materials into the spinal canal
tioning, such as dissection, rupture, or (Fig. 11.92).
pseudoaneurysm formation, are rare. CT with Spinal rods can potentially become dissoci-
multiplanar reformats is useful for initial eval- ated from the screws and migrate out of position.
uation of screw position. CTA can be used to The rods have been reported to migrate into the
evaluate for significant vascular injury, and spinal canal, retroperitoneum, and lower extremi-
MRI or CT myelogram can help assess for ties. Radiographs can be used to screen for rod
nerve root compression. displacement (Fig. 11.93).
a b
Fig. 11.91 Malpositioned screw. Axial (a) and coronal (b) CT images show the right pedicle screw (arrows) posi-
tioned too far medially, penetrating the spinal canal
a b
Fig. 11.92 Interbody fusion device retropulsion. The bullet-tip). Axial (a) and sagittal (b) images of the lumbar
patient is status post anterior-posterior lumbar fusion spine show retropulsion of the interbody box prosthesis
arthrodesis at L4–L5 and L5–S1 with placement of bio- into the spinal canal (arrow)
mechanical prosthetic interbody fusion device (Pioneer
Fig. 11.93 Rod migration. Frontal radiograph shows

inferior translation of the left posterior fusion rod, leaving
a gap between the superior end of the rod and the superior
pedicle screw
11.5.3 Hardware Loosening ated pseudarthrosis (Fig. 11.95), which can be

and Pseudarthrosis suggested by the following imaging findings:
11.5.3.1 Discussion 1 . Low to intermediate signal intensity

Spine hardware loosening is a fairly frequent find- defect between vertebral bodies or bone
ing on imaging, occurring in nearly 20% of patients graft on T1-weighted MRI or lucency sur-
and 5% of pedicle screws. Iliac screws followed by rounding the fusion area on radiographs
sacral screws are most commonly affected, perhaps or CT
related to torque. Loosening appears as a gap 2. Progressive spondylolisthesis
between the hardware and the bone greater than 3. Bone graft migration
2 mm (Fig. 11.94). Although loosening can be 4. Broken screws or lucency surrounding

related to the presence of particulate debris acti- hardware
vates phagocytes that release enzymes that result in 5. Bone graft resorption
osteolysis, it can be also a sign of underlying hard- 6. Motion between flexion and extension

ware infection. Furthermore, there can be associ- radiographs
Fig. 11.95 Transsacral interbody fusion loosening and

Fig. 11.94 Loosening. Axial CT image shows lucency pseudarthrosis. Sagittal CT cisternogram image shows
surrounding the bilateral screws lucency surrounding the device and across the previously
fused disc space (arrow)
11.5.4 Hardware and Periprosthetic (Fig. 11.96). The presence of a broken screw is

Fractures strongly associated with loosening and pseudar-
throsis, which should be sought on imaging. In
11.5.4.1 Discussion addition, hardware can alter the stresses on the
Pedicle screw fracture has an incidence of 0.5– surrounding bone and predispose to fractures.
2.5%. CT can readily demonstrate hardware frac- The pedicle is a common location for hardware-
ture, particularly if there is displacement related fracture (Fig. 11.97).
a b
Fig. 11.96 Screw fracture. The patient has a history of myelogram images show a displaced fracture (encircled)
three prior lumbar spine surgeries and presents with of the left L5 pedicle screw
mechanical back pain. Axial (a) and coronal (b) CT
Fig. 11.97 Periprosthetic fracture. Sagittal CT image

shows a lucency that traverses the left pedicle surrounding
the screw (encircled)
11.5.5 Cerebrospinal Fluid Leak The diagnosis and localization of cerebrospi-

nal fluid leak and pseudomeningoceles can be
11.5.5.1 Discussion elusive. A variety of imaging techniques are
Cerebrospinal fluid leakage occurs in about 2% available to evaluate the site of leakage, including
of patients after spine surgery and results from MRI/MR myelography and CT myelography.
dural and arachnoid defects, allowing cerebrospi- MRI in spinal cerebrospinal fluid leak syndrome
nal fluid to escape the thecal sac and infiltrate the usually reveals cerebrospinal fluid signal inten-
paraspinal surgical bed. In particular, pseudo- sity extradural fluid collections, spinal meningeal
meningoceles represent a form of cerebrospinal enhancement, and dilation of the epidural venous
fluid leak contained by a capsule of fibrous tissue plexus. However, the actual site of cerebrospinal
and have been reported to occur in over 5% of fluid leak is often not detectable with MRI. On
discectomy cases (Fig. 11.98). Nerve roots can the other hand, CT myelography can provide evi-
herniate into and become entrapped within pseu- dence delineate meningeal defects, the location
domeningoceles. Thus, patients typically present of extradural collections, and their relationship to
with orthostatic hypotension, but may also have bony structures. However, CT myelography
associated focal neurological deficits. Imaging results in radiation exposure and it is a slightly
options for cerebrospinal fluid leakage after spine invasive procedure.
surgery include conventional MRI to delineate Initial management of cerebrospinal fluid leak
the presence of the fluid collections, although the consists of cerebrospinal fluid diversion and epi-
exam can be limited by surgical hardware arti- dural blood patch. If the leak or pseudomeningo-
facts and there is a differential diagnosis for the cele persists, dural repair and even flap
extradural fluid, including abscess and seroma/ reconstruction may be warranted.
hematoma. Secondary findings that might be
present on post-contrast images related to spinal
hypotension include dilatation of the epidural
venous plexus and diffuse dural thickening and
enhancement. CT or MR myelography can pro-
vide a dynamic assessment that can help confirm
the presence and site of cerebrospinal fluid leak-
age with high accuracy. Nuclear medicine spinal
cisternograms are most suitable for detecting
slow, intermittent leaks.
Fig. 11.98 Pseudomeningocele. Sagittal CT myelogram

image shows a collection containing contrast material and
herniated nerve roots (arrow)
11.5.6 Postoperative Seromas utable to mass effect upon the spinal cord or
and Hematomas nerve roots. The majority of postoperative spi-
nal hematomas occur at the operated level and
11.5.6.1 Discussion rarely at a remote site. Prompt diagnosis and
Aseptic fluid collections are commonly found on decompression of symptomatic epidural hema-
early postoperative imaging along the surgical tomas is important for averting an adverse out-
approach after spine operations, including sero- come. Imaging diagnosis and assessment of the
mas and hematomas. Seromas consists of plasma extent of spinal canal stenosis can be made via
from disrupted vessels and inflammation from CT myelography or MRI. On MRI, epidural
injured soft tissues. There is an increased inci- hematomas can be heterogeneous with a mar-
dence of sterile seromas and painful edema in the bled appearance and of variable signal depend-
lumbar region after posterolateral fusion with ing on the age of the hematoma. For example,
rhBMP-2. Seromas typically appear as simple hyperacute hematomas tend to have intermedi-
fluid collections on imaging (Fig. 11.99). ate signal on T1 and bright on T2-weighted
Postoperative spinal epidural hematomas are sequences (Fig. 11.100).
clinically significant in up to 1% of cases, attrib-
Fig. 11.100 Epidural hematoma. The patient underwent

laminectomy and developed new lower extremity deficits
caused by a large epidural hematoma confirmed on emer-
gent decompression. Sagittal T2-weighted MRI shows a
posterior epidural fluid collection (arrow) that severely
narrows the spinal canal in conjunction with underlying
degenerative disease
Fig. 11.99 Seroma. Axial T2-weighted (a) and

T1-weighted (b) MR images show a simple fluid collec-
tion in the posterior paraspinal soft tissue surgical bed
11.5.7 Surgical Site Infections cases of postoperative spine infection

(Fig. 11.103). Other than removing old hard-
11.5.7.1 Discussion ware and washout, antibiotic- impregnated
Infection related to spine surgery has an overall methyl methacrylate beads are sometimes left in
incidence of 1.9% and is defined as occurring the surgical cavity for direct site treatment
within 30 days of surgery or within 12 months (Fig. 11.104).
of placement of foreign bodies and can be cate-
gorized by the depth of surgical tissue involve-
ment, including superficial, deep incisional, or a
organ and surrounding space. Staphylococcus
aureus is the most common causative organism.
MRI with contrast is generally the modality of
choice for evaluating postoperative infections.
Rim-enhancing fluid collections, bony erosions
and enhancing, and paraspinal inflammation are
suggestive of infection (Figs. 11.101 and
11.102). Hardware removal is often necessary in
Fig. 11.102 Wound infection. Sagittal (a) T2-weighted

and post-contrast fat-suppressed T1-weighted (b) MR
Fig. 11.101 Discitis-osteomyelitis. Sagittal post- images show a fluid collection (arrows) with surrounding
contrast T1-weighted MRI shows enhancement in the ver- enhancement and a draining sinus to the overlying skin in
tebral bone marrow and prevertebral soft tissues at L5–S1 the posterior paraspinal soft tissues along the surgical
surrounding the intervertebral disc prosthesis approach following minimally invasive microdiscectomy
Fig. 11.103 Hardware removal and abscess drainage.

Axial CT shows the site of pedicle screw removal (arrow)
and paraspinal muscle abscess with drainage catheter
from hardware infection
a b
Fig. 11.104 Antibiotic beads. Axial (a) and sagittal (b) CT images show the hyperattenuating antibiotic-impregnated
methyl methacrylate beads at multiple levels adjacent to the surgical hardware
11.5.8 Postoperative Neuritis 11.5.9 Arachnoiditis

Aseptic inflammatory neuritis can occur follow- Postoperative arachnoiditis is an inflammatory
ing lumbar spine surgery due to mechanical fac- process affecting the nerve roots that may be
tors, such as compression, stretching, contusion, associated with anesthetics, chemotherapy, cer-
or transection. Diagnostic imaging is useful for tain contrast agents, intradural hemorrhage, sub-
excluding a mechanical etiology, such as stances released from the intervertebral discs, the
impingement by screws or disc material. surgery itself, and infection. This condition pro-
Furthermore, MRI may demonstrate enhance- duces symptoms in 6–16% of spine surgery
ment of the nerve roots (Fig. 11.105). This find- cases. Three imaging patterns of arachnoiditis
ing has a 94% positive predictive value for have been described, which can be well delin-
residual or recurrent clinical symptoms. eated on MRI:
Furthermore, there may be an association
between nerve root changes, postoperative epi- 1. “Empty sac” appearance in which the nerve
dural fibrosis, and the development of sciatica. roots are peripherally distributed (Fig. 11.106)
2. “Clumped” nerve roots centrally within the
dural sac
3. “Mass” comprised of the dural-based aggre-
gated nerve roots
Fig. 11.106 Arachnoiditis with “empty sac” sign. Axial

T2-weighted MRI shows that the cauda equina nerve roots
are adherent to the margins of the thecal sac. Laminectomy
posterior fusion and interbody fusion were performed
Fig. 11.105 Neuritis. The patient presented with left
lower extremity weakness after surgery. Sagittal post-
contrast T1-weighted MRI shows cauda equina nerve root
enhancement (arrow)
The presence and degree of contrast enhance- lesions that have high signal on T1-weighted
ment is variable for any of these patterns of sequences and variable signal on T2-weighted
arachnoiditis. A rare form of arachnoiditis is sequences. CT with multiplanar reformats is
arachnoiditis ossificans, which is characterized helpful for confirming the presence of arach-
by calcified plaques or ossification forms along noiditis ossificans, which shows linear bone
the leptomeninges. On MRI, arachnoiditis ossifi- attenuation structures along the nerve roots
cans appears as linear or mass-like intrathecal (Fig. 11.107).
a b
Fig. 11.107 Arachnoiditis ossificans. Axial (a) and sagittal (b) CT images show linear intrathecal calcification/ossifi-
cation (arrows). There is evidence of prior laminectomy at the same level
11.5.10 Residual/Recurrent Disc and diffusely after contrast administration on

Material Versus Epidural MRI (Fig. 11.108). Scar can also encase and
Scar retract the thecal sac and nerve roots. On the
other hand, disc material enhances peripherally
11.5.10.1 Discussion but can fill with contrast on delayed imaging and
Both postoperative epidural fibrosis (scar) and tends to displace or compress the nerve roots or
residual or recurrent disc material are rather com- thecal sac (Fig. 11.109). The size of the scar
mon occurrences that can produce symptoms. decreases or remains the same after 6 months in
Both disc material and epidural fibrosis can be the majority of cases. Similarly, residual disc
hypo- or isointense on T1-weighted sequences material can also involute over time. MRI has an
and hyperintense on T2-weighted sequences rela- accuracy of 96–100% for differentiating between
tive to the annulus. However, scar enhances early scar and disc.
a b
Fig. 11.108 Epidural fibrosis. Axial T2-weighted (a) and post-contrast T1-weighted (b) MR images show homoge-
neously enhancing soft tissue surrounding the right L5 nerve root (arrow)
a b
Fig. 11.109 Residual/recurrent disc material. Sagittal level of the L5 vertebral body (arrows). Post-contrast
(a) and axial (b) T2-weighted MR images show a seques- fat-suppressed T1-weighted MRI (c) show enhancement
tered disc fragment that compresses the thecal sac at the surrounding the disc fragment (arrow)
11.5.11 Postoperative Synovial Cyst leg pain that may or may not be accompanied by
back pain. MRI can readily demonstrate synovial
11.5.11.1 Discussion cysts and the associated mass effect (Fig. 11.110).
Synovial (juxtafacet) cysts are responsible for These lesions are contiguous with the facet joint,
about 1% of cases of failed back surgery syn- and their contents generally follow fluid signal,
drome. These can form as a consequence of although these may contain hemorrhage and
altered biomechanics on the facet joints and may solid components. Peripheral enhancement can
also be predisposed by disruption of the facet also be observed. Cyst puncture and aspiration
capsule. Patients tend to present with ipsilateral can provide symptomatic relief.
a b
Fig. 11.110 Postoperative de novo synovial cyst. The and right leg pain. Axial (a) and sagittal (b) T2-weighted
patient underwent L3 and L4 laminectomy for decom- MR images show a juxtafacet cyst (arrows) arising from
pression 6 months prior. There was no synovial cyst prior the right L4–L5 facet joint, where there is an effusion and
to surgery, and the patient initially did well after surgery, compression of the adjacent nerve roots
but a few months after, the patient began to develop back
11.5.12 Residual/Recurrent Tumors free survival. Nevertheless, follow-up imaging is

often performed to monitor for residual/recurrent
11.5.12.1 Discussion tumor. MRI with contrast is generally the modal-
The risk of residual or recurrent spinal tumor ity of choice for evaluating residual/recurrent spi-
depends largely on the type of tumor and treat- nal tumor (Fig. 11.111). Initial postoperative
ment. In general, postoperative imaging evalua- changes with enhancement can sometimes mimic
tion should cover the entire length of the surgical residual tumors. Follow-up MRI can help differ-
approach, since recurrence can occur anywhere entiate between these two processes, whereby
along this path, especially at the original tumor residual tumor may persist and even grow.
margins. Gross total resection is often feasible Comparison with prior imaging is also very use-
for schwannomas, meningiomas, paraganglio- ful. It is important to image along the entire
mas, myxopapillary ependymomas, ependymo- length of the surgical approach for assessment of
mas, and hemangioblastomas. Although tumor recurrence, which may include the abdo-
astrocytomas are typically infiltrative neoplasms, men or chest if an anterior approach has been
radical resection can result in long progression- implemented.
a b
Fig. 11.111 Residual tumor. The patient has a history of surgery shows a tiny focus of enhancement adjacent to the
conus medullaris schwannoma resected via a posterior conus medullaris (arrow). Sagittal post-contrast
approach. Preoperative sagittal post-contrast T1-weighted T1-weighted MRI obtained 6 months later (c) shows
MRI (a) shows a heterogeneously enhancing mass that interval increase in size of the enhancing nodule adjacent
involves the proximal cauda equina. Postoperative sagittal to the conus medullaris (arrow), but resolution of the
post-contrast T1-weighted MRI (b) obtained 1 week after cauda equina nerve root enhancement
11.5.13 Inclusion Cysts

c
11.5.13.1 Discussion
Cutaneously derived inclusion cysts or epider-
moids can occasionally form within the spinal
canal and cause pain and neurological deficits
following a spine procedure. Most cases have
been reported following myelomeningocele
repair, although this complication can presum-
ably result from any other procedure, including
lumbar punctures, in which fragments of skin are
introduced into the spinal canal. The cysts can
grow and exert mass effect upon the nerve roots.
MRI typically reveals low T1 and high T2 signal
(Fig. 11.112). The presence of high signal on
diffusion-weighted imaging can be helpful in dis-
tinguishing epidermoid from arachnoid cyst.
a b
Fig. 11.112 Inclusion cysts. The patient has a history of ovoid cystic masses in the posterior spinal canal at the site
prior myelomeningocele repair and presents with a lump of prior myelomeningocele repair. Sagittal DWI (c) and
at the surgical site. Sagittal T2-weighted (a) and ADC map (d) show that the lesions display restricted
T1-weighted (b) MR images show two well-defined, diffusion
c d
11.5.14 R
etained Bone Fragments 11.5.15 Retained Surgical Tools
and New Bone Formation
11.5.14.1 Discussion Various tools are used during spine surgery. In par-
Residual bone fragments after spine surgery can ticular, drilling procedures are commonly per-
migrate and impinge upon neural structures. The formed during spine surgeries, which involve the
bony fragments are readily depicted on CT use of drill bits. Rarely, the drill bits can break and
(Fig. 11.113). Facet and pedicle fractures after become retained or even migrate. The small-
laminectomy can produce similar findings. diameter bits are more likely to break during sur-
Alternatively, bone can regrow after surgery and gery. Small retained drill bit fragments can initially
cause stenosis. go unnoticed, although patients may present with
recurrent or new symptoms after surgery. CT is the
modality of choice for evaluating possible retained
drill bit fragments, which appear as linear metallic
attenuation structures on CT (Fig. 11.114).
a
a
Fig. 11.113 Retained bone fragment. Axial (a) and sag-

ittal (b) CT images demonstrate sequela of prior lumbar
laminectomy and a portion of retained lamina within the
spinal canal (arrows). There is also an interbody fusion
cage at L4–L5 Fig. 11.114 Broken drill bit fragment. Axial (a) and sag-
ittal (b) CT images show a cylindrical metallic object
(arrows) posterior to the L5–S1 disc
11.5.16 Gossypiboma after spine surgery. Most gossypibomas reside in

the paraspinal soft tissues in the vicinity of the
11.5.16.1 Discussion surgical site (Fig. 11.115). These usually range in
Retained surgical sponges can form gossypi- size from 3.5 to 5.0 cm. Patients often present
bomas, which are masses of cotton surrounded with nonspecific back pain. On MRI, gossypi-
by foreign-body reaction. These are uncommon bomas characteristically display hyperintense
a b
Fig. 11.115 Gossypiboma. The patient has a history of was found. Sagittal T2-weighted (b), T1-weighted (c),
spine surgery for lumbar stenosis many years prior in an and post-contrast T1-weighted (d) MR images demon-
underdeveloped country. Axial CT (a) shows well-defined strate a mass in the right paraspinal muscles with periph-
right paravertebral mass (arrow). No radiopaque marker eral enhancement and a hyperintense core on T2 (arrows)
centers surrounded by low signal intensity on 11.5.17 Adjacent Segment

T2-weighted images and peripheral enhancement Degenerative Disease
on post-contrast T1-weighted sequences. Most
sponges contain radiopaque markers that can be 11.5.17.1 Discussion
recognized on CT and radiographs. However, Adjacent segment disease is a process related to
some institutions may use sponges without radi- spinal fusion in which degenerative change may
opaque markers. On CT, gas bubbles or calcifica- develop at an accelerated pace at the mobile level
tions may be apparent, depending on the age of next to fused level. This can lead to symptoms
the gossypiboma. that can require additional surgical intervention.
Radiographic signs of degenerative change adja-
cent to a fuse level are not uncommon. Potential
findings include facet hypertrophy, disc hernia-
tion, loss of disc space height, and endplate
changes (Fig. 11.116). The incidence of symp-
tomatic adjacent degenerative disease is higher
with pedicle instrumented fusion than other types
of instrumented fusion.
a b
Fig. 11.116 Development of adjacent level degenerative image (a) shows no significant degenerative disease at
disease. The patient underwent transforaminal lumbar L1–L2. Postoperative sagittal CT image (b) obtained
interbody fusion at L3–L4 and L4–L5 and posterior lum- 2 years later shows new facet hypertrophy (arrow), disc
bar arthrodesis L2–L5. Two years later, the patient began space narrowing, and endplate sclerosis at L1–L2. Spinal
to experience symptoms consistent with cauda equina and fusion hardware is partially visible
conus medullaris compression. Preoperative sagittal CT
11.5.18 Postoperative Deformity of patients with flat-back syndrome. Sagittal CT

or MRI and full-length lateral views of the spine
11.5.18.1 Discussion with the knee and hips flexed are particularly
Postoperative deformity can manifest as kypho- useful for confirming the diagnosis. In addition,
sis and flat-back syndrome. Flat-back syndrome these studies are necessary for planning correc-
is an iatrogenic loss of lumbar lordosis due to the tive procedures when conservative therapy fails.
presence of thoracolumbar lordosis. Clinically, Several techniques are available to correct lum-
this condition consists of forward inclination of bar spine sagittal plane deformities, including
the spine, back pain, and inability to stand erect. pedicle subtraction (Fig. 11.117) and wedge oste-
Imaging plays an important role in the work-up otomies (Fig. 11.118).
a b
Fig. 11.117 Postoperative deformity treated with pedi- gically fused levels. Lateral radiograph after osteotomy
cle subtraction osteotomy. The patient presented with (b) shows resection of a portion of the pedicles and poste-
long-standing focal kyphosis following fusion from L4 to rior vertebral body with correction of lumbar lordosis
the sacrum. Lateral radiograph (a) shows straightening of (bracket)
L4 to the sacrum and kyphosis at the level above the sur-
a 11.6 Intrathecal Spinal

Infusion Pump
11.6.1 Discussion
Intrathecal spinal infusion pump systems have

been used to manage patients with intractable
pain related to metastatic disease as well as those
with spasms related to stroke, multiple sclerosis,
or cerebral palsy. These devices resemble spinal
stimulators on imaging, but the pump tends to be
bulkier than the pulse generator (Fig. 11.119).
Implanted infusion pumps are generally MRI
compatible. Similar to spinal stimulators, patients
may experience complications such as infection,
device malposition, and spinal hypotension,
which can result in diffuse meningeal enhance-
ment and prominence of the epidural venous
plexus (Fig. 11.120). Other complications include
epidural hematoma, catheter breakage to spinal
cord compression secondary to fibrotic mass for-
mation, which is uncommon.
Fig. 11.118 Postoperative deformity treated with verte-

bral wedge osteotomy. Sagittal CT image (a) shows loss
of the normal lumbar lordosis after previous lumbar sur-
geries. Sagittal (b) CT image obtained after wedge oste-
otomy shows a surgical defect in the posterior L3 vertebral
body for wedge osteotomy (arrow). This vertebral body is
now taller anteriorly than posteriorly, thereby restoring
lumbar lordosis
a b
Fig. 11.119 Baclofen pump components. The patient (b) show the pump mechanism in the subcutaneous tis-
has a history of cerebral palsy with a baclofen pump for sues and the infusion catheter (arrows) within the spinal
spastic quadriparesis. Scout image (a) and axial CT image canal. Photograph of the pump device (c)
a b
Fig. 11.120 Spinal hypotension syndrome. The patient T1-weighted MR images show diffuse pachymeningeal
presented with postural headaches after baclofen pump thickening and enhancement, as well as prominence of the
insertion. Coronal (a) and sagittal (b) post-contrast anterior spinal venous epidural plexus (arrow)
11.7 Spinal Cord Stimulators pack and pulse generator either kept externally
or buried in the subcutaneous tissues, con-
11.7.1 Discussion nected to an electrode that is inserted into the
epidural space adjacent to the dorsal column or
Spinal cord stimulators are used to treat patients dorsal root ganglion. About 50% of patients
with intractable pain and are positioned against experience pain relief. Complications related to
the dorsal column. The models that consist of spinal cord stimulators include intracranial/spi-
paddle electrodes require laminectomy for nal hypotension secondary to cerebrospinal
electrode positioning, while strip electrode fluid leakage, migration or malposition,
models can be inserted percutaneously essen- decreased effectiveness over time secondary to
tially at any level of the spine (Fig. 11.121). the formation of scar tissue, epidural hema-
Spinal cord stimulators consist of a battery toma, and infection (Fig. 11.122).
a b
Fig. 11.121 Thoracic spinal cord stimulator. Lateral (a) various models of spinal cord stimulators, with strip elec-
and frontal (b) radiographs show the battery pack in the trodes shown on top right and paddle electrodes shown on
lower back and the electrodes in the thoracic spinal canal the bottom right (c)
(arrow). Photographs of the battery packs on the left and
Fig. 11.122 Infected spine stimulator lead. Sagittal CT

image shows a subcutaneous fluid collection (arrow) sur-
rounding the spinal stimulator wire
11.8 Filum Terminale Sectioning otherwise explain the clinical deterioration.

Discontinuity, along with thickening of the upper
11.8.1 Discussion and lower remnants of the sectioned filum, con-
stitutes evidence of a detethered filum
Detethering of a tethered spinal cord by transect- (Fig. 11.123). The presence of conus relaxation,
ing or resecting a fatty filum terminale is per- indicated by elevation or a more ventral position,
formed to alleviate associated neurological is also reassuring, but is not consistently observed.
symptoms. Postoperative MRI of the lumbar Obtaining prone and supine imaging during the
spine following detethering is generally per- MRI exam can also be useful, in which no appre-
formed if patients develop new symptoms sug- ciable translation of the conus medullaris is
gestive of retethering or to assess associated observed when rethethering has occurred
conditions in patients with dysraphism that could (Fig. 11.124).
a b
Fig. 11.123 Filum terminale sectioning. Preoperative sagittal T1-weighted MRI (b) shows a wide gap in of the
sagittal T1-weighted MRI (a) shows a low-lying conus fibrofatty filum with retraction and slight thickening of
medullaris and fibrofatty filum terminate. Postoperative both remaining segments (arrows)
a b
Fig. 11.124 Rethethering. Supine (a) and prone (b) sag- conus medullaris, which is low-lying and posteriorly devi-
ittal T2-weighted MR images show findings related to ated alongside the dura
prior detethering surgery, but no shift in the position of the
11.9 Percutaneous Spine neural foramen and spinal canal (Figs. 11.128,

Treatments 11.129, and 11.130), which can result in neuro-
logical deficits and predisposes to degenerative
11.9.1 Vertebral Augmentation spondylosis. Overall, this type of complication
occurs in 30–75% of cases, whether or not an
11.9.1.1 Discussion intravertebral cleft exist. The heat generated from
Kyphoplasty and vertebroplasty are percutane- the exothermic reaction as the cement hardens
ous interventions that have been used to treat a can burn the spinal cord or nerve roots. However,
variety of conditions including of osteoporotic significant neurological symptoms result in only
vertebral compression fractures, certain spine a minority of cases. In addition, if there is preex-
tumors, and selected traumatic fractures. isting spinal canal stenosis and the amount of
Vertebroplasty consists of injecting polymethyl- cement is large, extravasation can be a major
methacrylate cement into the affected vertebral complication of vertebroplasty or kyphoplasty.
body, while kyphoplasty involves the use of a Radiographs and CT can readily depict the hyper-
balloon that is first inflated in the vertebral body attenuating cement extending outside the verte-
and then deflated prior to cement injection. bral body. MRI or CT myelography are useful for
Skyphoplasty is another cement vertebral aug- evaluating whether the cement impinges upon
mentation technique that is no longer imple- the spinal cord and nerve roots.
mented. The procedure involves the use of SKy Cement embolization to the pulmonary arter-
bone expander (Disc Orthopaedic Technology/ ies occurs in 4.6–6.8% of cases of kyphoplasty/
Disc-O-Tech, Monroe Township, New Jersey), vertebroplasty. Leakage of cement into the para-
which enlarges like an accordion into a popcorn- vertebral veins is a strong risk factor for cement
like crenulated configuration. Compared with embolization to the lungs. Underlying multiple
kyphoplasty device, skyphoplasty generates myeloma may also be a risk factor. However, the
higher pressures, expands more predictably, incidence of this complication is the same for
requires a larger cannula, and cannot be reposi- kyphoplasty as for vertebroplasty. On chest imag-
tioned once it is deployed. ing, pulmonary artery cement emboli characteris-
The imaging features for vertebroplasty and tically appear as high attenuation tubular or
kyphoplasty are similar: cement should be con- branching structures in the distribution of the
fined to the intramedullary space of the verte- pulmonary arteries (Fig. 11.131). The cement
bral body with disruption and compaction of the fragments can range widely in size, and small
trabeculae (Fig. 11.125). However, the cement fragments are most readily identified on non-con-
deposits from vertebroplasty tend to have a trast CT.
more diffuse and granular appearance, while The incidence of new compression fractures
cement deposits from kyphoplasty tend to be following vertebroplasty or kyphoplasty ranges
more localized and globular, filling the cavity from 5% in patients with idiopathic osteoporosis
produced by balloon dilatation. A small increase and up to about 45% in patients with steroid
in vertebral body height is sometimes observed induced or secondary osteoporosis. Over two-
following vertebral augmentation (Fig. 11.126). thirds of new fractures occur in the adjacent ver-
The cement is hyperattenuating on radiographs tebral body and present within 3 months of the
and CT and very low signal intensity on all MRI procedure (Fig. 11.132). Extrusion of cement
sequences. Skyphoplasty produces the charac- into the disc space appears to increase the risk for
teristic configuration of cement deposition that adjacent vertebral body fracture, likely as a result
is often present on post-procedure imaging of altered biomechanics. Other factors associated
(Fig. 11.127). with adjacent vertebral body fracture include a
During vertebral augmentation, cement can thoracolumbar junction location and greater
leak outside of the vertebral body and into the height restoration.
Fig. 11.127 Skyphoplasty. Axial CT image shows

cement with characteristic lobulated margins in the verte-
Fig. 11.125 Kyphoplasty and vertebroplasty. Sagittal bral body (encircled). There is also cement in the cannula
CT image shows the granular deposits of vertebroplasty insertion path across the left pedicle
cement and the more globular deposits of cement from
kyphoplasty, all of which are confined to the vertebral
bodies
a b
Fig. 11.126 Increased vertebral body height after verte- T2-weighted MRI after vertebral augmentation (b) shows
bral augmentation. Initial sagittal T2-weighted MRI (a) interval elevation of the superior endplate of the treated
shows a thoracic compression fracture. Sagittal vertebral body (arrow)
Fig. 11.128 Neural foramen cement leakage. Sagittal

CT image of the lumbar spine shows cement within filling Fig. 11.129 Disc space and spinal canal cement leakage.
a neural foramen (arrow) Sagittal CT image shows cement extending into the adja-
cent intervertebral disc spaces, even extending into the
spinal canal (arrow)
a b
Fig. 11.130 Degenerative disc disease related to cement the adjacent disc space and interval development of end-
extravasation. Prevertebroplasty lateral radiograph (a) plate sclerosis, worsening kyphosis and formation of a
shows a thoracic vertebral compression fracture. Post- bridging osteophyte (arrow)
vertebroplasty lateral radiograph (b) shows cement within
a b
Fig. 11.131 Cement intravasation and pulmonary embo- Axial CT image (a) shows the presence of pulmonary
lism. The patient has a history of multiple myeloma with artery cement embolism (arrow). Axial CT image at
compression fractures, for which the patient was treated another level (b) shows intravasation of cement into the
with vertebral augmentation in the thoracic spine. After left paravertebral veins (encircled)
the procedure, the patient experienced shortness of breath.
a b
Fig. 11.132 Adjacent vertebral body fracture. The time. T1-weighted MRI after kyphoplasty (b) show
patient has a history of osteoporosis and presented with cement in the L2 and an acute L1 vertebral body compres-
new pain 3 weeks after L2 kyphoplasty. Initial sagittal sion fracture as evidenced by edema and mild loss of
T1-weighted MRI (a) shows an acute compression frac- height (arrow)
ture of the L2, but the L1 vertebral body is normal at this
11.9.2 Kiva Device 11.9.3 Sacroplasty

The Kiva VCF (vertebral compression fracture) Analogous to kyphoplasty and vertebroplasty,
system flexible implant is designed to provide sacroplasty is a minimally invasive procedure
structural support to the vertebral body and that involves percutaneous injection of polymeth-
enables injection of bone cement during vertebral ylmethacrylate cement into the sacral ala for
augmentation from T6 to L5. The implant appears treatment of sacral insufficiency fractures
as a spiral-shaped structure comprised of PEEK, (Fig. 11.134). The rate of symptomatic improve-
which is visible on x-ray imaging modalities ment ranges from 50% immediately after the pro-
(Fig. 11.133). cedure to 90% at 1 year. Complications of
sacroplasty include premature hardening, leak-
age of cement into the sacral neural foramina and
into the sacroiliac joint, which can limit range of
motion, and venous intravasation of cement with
the risk of pulmonary embolism.
Fig. 11.133 Kiva device. Frontal radiograph obtained

during percutaneous delivery of the device shows the heli- Fig. 11.134 Sacroplasty. The patient has a history of
cal structure within the fractured vertebral body (Courtesy right sacral insufficiency fracture. Coronal CT image
of Benvenue Medical, Inc.) shows cement within the right sacral ala (arrow)
11.9.4 Percutaneous Interbody combination with facet or pedicle screws. On

Fusion imaging, the implant appears as an ovoid hyper-
attenuating mass within the disc space
11.9.4.1 Discussion (Fig. 11.135). Overtime, solid bony fusion
Percutaneous interbody fusion is a minimally should form across the disc space. Potential
invasive method for providing structural support complications include but are not limited to
to the level being fused. This can be accom- extrusion and failed fusion.
plished using contained bone graft implant, Another type of percutaneous disc interven-
such as OptiMesh. The device consists of an tion is nucleoplasty in which radiofrequency
expandable polyethylene terephthalate meshed ablation is performed for treatment of disc her-
bag or pouch that is inserted into a voided disc niation. This does not have any significant imag-
space and then filled with bone graft material. ing correlates other than decrease in the disc
The implant can be used as stand-alone or in herniation if successful.
a b
Fig. 11.135 Sagittal CT image (a) shows hyperattenuating material within the L5–S1 disc space (arrow). Photograph
of OptiMesh (b)
11.9.5 CT-Guided Epidural Blood fluid leaks. The procedure essentially consists of
Patch injecting a small amount of contrast material and
autologous blood into the epidural space in the
11.9.5.1 Discussion region of the suspected location of the dural
CT-guided percutaneous patching targeted to the defect. The distribution of the injected contrast
dural defect is a minimally invasive alternative to and blood can be observed on CT and MRI soon
surgery for the treatment of spinal cerebrospinal after the procedure (Fig. 11.136).
a b
Fig. 11.136 CT-guided epidural blood patch. Initial sag- posterior epidural space (arrow). The blood patch appears
ittal STIR MRI (a) shows a fluid collection in the poste- as a fluid collection (arrow) along the dorsolateral epi-
rior subcutaneous tissues related to cerebrospinal fluid dural space related to recent blood patch with mild local
leakage and postoperative findings related to microdiscec- mass effect on the thecal on the sagittal STIR MRI
tomy in the lower lumbar spine. Axial CT image (b) obtained 1 day later (c), but the fluid posterior subcutane-
obtained at the completion of the epidural blood patch ous fluid collection has diminished
procedure shows the contrast containing fluid in the right
11.9.6 Percutaneous Perineural Cyst under image guidance. The cyst contents can be
Decompression aspirated, thereby relieving the mass effect.
Catheters that drain the cyst into the subarach-
11.9.6.1 Discussion noid space can also be inserted (Fig. 11.137). The
Perineural cysts can occasionally cause symp- resulting decrease in size of the cyst and position
toms that warrant treatment, such as radicular of the drainage catheter can be assessed on MRI
pain. Percutaneous cyst drainage is a minimally or CT myelography.
invasive treatment option that can be performed
a b
Fig. 11.137 Percutaneous sacral perineural cyst decom- Postoperative sagittal T2-weighted MR image (b) shows a
pression with drainage catheter. Preoperative sagittal drainage catheter (arrow) inserted within the cyst and
T2-weighted MRI (a) show a large intrasacral perineural interval decrease in size of the cyst
cyst (*) with remodeling of the surrounding bone.
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Imaging of Vascular
and Endovascular Surgery 12
Daniel Thomas Ginat, Javier M. Romero,
and Gregory Christoforidis
12.1 Vascular Surgery supply the posterior cerebral artery. Regardless of

the particular vessels used, EC-IC bypass is per-
12.1.1 Direct Extracranial- formed via a small craniectomy in the temporal
Intracranial Revascularization region, so as to expose the Sylvian fissure and the
right temporal lobe. On follow-up angiography,
12.1.1.1 Discussion increase in caliber of the recipient and donor
Extracranial-intracranial (EC-IC) bypass is a arteries can be observed. On the other hand, basal
revascularization option for complex cerebrovas- collateral vessels often regress. Graft patency can
cular disease such as moyamoya in adults and be readily assessed via MRA or CTA. Stenosis or
flow replacement prior to planned vessel sacrifice occlusion of the bypass typically occurs at or near
for treatment of complex and fusiform aneurysms the anastomosis (Fig. 12.4). Correlation with pre-
that are not amenable to coiling or clipping. contrast images is recommended, since early clot
Usually in EC-IC bypass, the superficial temporal can appear hyperattenuating, mimicking graft
artery is anastomosed to a middle cerebral artery patency on CTA. A pitfall with time-of-flight
branch (Fig. 12.1). Alternatively, saphenous vein MRA in particular is the loss of signal associated
grafts can be used, in which the venous graft nor- with the presence of adjacent surgical clips, which
mally appears relatively patulous with respect to can obscure the bypass, mimicking a stenosis
the artery (Fig. 12.2). If these options fail, the (Fig. 12.5). However, the presence of flow-related
occipital artery can be anastomosed to the middle enhancement distally suggests that the vessel is
cerebral artery (Fig. 12.3), or it can be used to indeed patent.
D.T. Ginat, M.D., MS (*) • G. Christoforidis, M.D.

Department of Radiology, Pritzker School of
Medicine, University of Chicago, Chicago, IL, USA
J.M. Romero, M.D.
Massachusetts General Hospital, Boston, MA, USA

DOI 10.1007/978-3-319-52341-5_12
a a
Fig. 12.1 MCA-STA bypass. The 3D MIP MRA (a) and

3D reformatted CTA image (b) show the superficial artery
(arrows) entering the craniotomy and anastomosing with
the prominent right superficial temporal artery (arrow-
heads) and M3 segment of the right middle cerebral artery
Fig. 12.2 EC-IC bypass with saphenous vein graft.

Curved planar reformatted CT (a) and 3D CT (b) images
show a large caliber saphenous vein graft (arrows) that
connects the proximal ECA to the MCA
12 Imaging of Vascular and Endovascular Surgery 629
Fig 12.3 Occipital artery-MCA bypass. The patient has a artery (arrowhead) entering an additional craniotomy. The
history of failed left STA-MCA bypass. The 3D reformat- 3D reformatted CTA image (b) shows a patent anastomo-
ted CTA image (a) shows the microcraniotomy (encir- sis between the left occipital artery (arrowhead) and left
cled) for the failed STA-MCA bypass and the left occipital middle cerebral artery (arrow)
a b
Fig. 12.4 EC-IC bypass occlusion. The patient has a his- MIP image (b) shows a patent bypass. Follow-up axial CT
tory of complex left MCA aneurysm requiring left ICA image (c) obtained 11 months later shows increased
occlusion and EC-IC bypass. Initial axial CT image (a) encephalomalacia. The corresponding axial CTA MIP
shows a small amount of encephalomalacia in the left image (d) now shows occlusion of the bypass near the
temporal lobe and insula. The corresponding axial CTA anastomosis (encircled)
c d
a b
Fig. 12.5 Metal artifact simulating steno-occlusive dis- (b) shows focal loss of signal (arrow) along the course of
ease of the STA-MCA bypass. Axial time-of-flight MRA the left superficial temporal artery, but there intact flow-
image (a) shows susceptibility effect from a metallic clip related enhancement distally (arrow), indicating patency
(arrow) adjacent to the left superficial temporal artery of the vessel
branch (arrowhead). The corresponding MRA MIP image
12.1.2 Indirect Extracranial- inserting the temporal muscle deep to the craniot-
Intracranial Revascularization omy flap directly upon surface of the brain. During
the early postoperative period, the swollen muscle
12.1.2.1 Discussion can exert mild mass effect upon the underlying brain
Indirect surgical revascularization can be per- parenchyma (Fig. 12.8). Postoperative angiography
formed as part of complex aneurysm obliteration reveals good revascularization in the majority of
and moyamoya disease primarily in adults. There cases.
are several methods for establishing indirect Encephaloduroarteriosynangiosis (EDAS)/
revascularization, including multiple burr holes, pial synangiosis consists of creating a defect in
encephaloduromyosynangiosis, and the dura and arachnoid to enable direct suturing
encephaloduroarteriosynangiosis/pial synangio- of the superficial temporal artery to the pia
sis, among others. (Fig. 12.9). Following successful synangiosis,
Creating burr multiple holes (Fig. 12.6) can angiography shows progressive reduced flow in
promote neovascularization to the brain surface. the moyamoya vessels and increase in size of the
On post-contrast images, enhancement across the superficial temporal artery.
burr holes can be appreciated and ADC maps can Angiography is well suited for monitoring the
show increased diffusivity. Depending on the effects of synangiosis. Indeed, the angiographic
particular technique, favorable results are findings of synangiosis are characteristic and
achieved in nearly 90% of cases. However, in include early filling of the middle cerebral artery
some cases, the delicate anastomoses may not branches via ECA injection, enlargement of the
provide sufficient revascularization, and cerebral superficial temporal artery and middle menin-
infarction may result as the underlying disease geal artery, and the presence of transpial or
process ensues. transdural collateral vessels. Progression of
Encephaloduroarteriomyosynangiosis (EDAMS) proximal MCA or ICA stenosis is often apparent
consists of creating a linear craniotomy, narrow despite a successful surgical and clinical out-
dural opening, and placing temporalis muscle flaps come, presumably due to diverted blood flow
directly upon the exposed pial surface to stimulate through the ECA circulation. In fact, the lack of
collateral development (Fig. 12.7). The superficial MCA or ICA stenosis is associated with a rela-
temporal artery and attached flap are then sutured to tively poor outcome. CT and MRI can be used to
the dura. Alternatively, encephalomyosynangiosis assess for complications, which include recur-
(EMS) can be performed for increasing both intra- rence of ischemic events and chronic subdural
cranial and extracranial collateral circulation by hematomas.
Fig. 12.6 Multiple burr holes for encephalogaleoperios-

teal synangiosis. 3D CT image shows multiple left cal-
varial burr holes
a b
Fig. 12.7 Encephaloduromyosynangiosis. The patient placed on the exposed brain surface to allow for additional
has a history of left MCA occlusion as well as right MCA synangiosis. Axial CTA image (a) performed shortly after
and ACA stenosis. The patient was managed medically surgery shows a left temporal microcraniotomy and tem-
but recently developed repeated episodes of transient isch- poralis muscle flap with a superficial temporal artery
emic attacks to the left hemisphere. Consequently, an branch and fascial cuff (arrow) juxtaposed against the
onlay external to internal carotid artery bypass with myo- brain surface. Lateral digital subtraction angiography
synangiosis was performed. Specifically, a direct anasto- imaged obtained by injection through the left common
mosis was not feasible due to lack of adequately patent carotid artery 3 months after surgery (b) demonstrates
cortical branches. Rather, the superficial temporal artery small collateral vessels (encircled) communicating
branch was placed over the brain surface along with its between the intracranial and extracranial arteries. Axial
fascial cuff. This was done after multiple openings were CTA obtained 9 months after surgery (c) also shows for-
made in the arachnoid to allow for percolation of cerebro- mation of small collateral vessels (encircled) that bridge
spinal fluid. In addition, the temporalis muscle flaps were the temporal lobe cortex and temporalis muscle
Fig 12.8 Encephalomyosynangiosis. Coronal CT image

obtained during the early postoperative period shows the
left temporalis muscle (arrow) tunneled under the left cra-
niotomy flap, where it exerts mild mass effect upon the
brain parenchyma
a b
Fig. 12.9 Encephaloduroarteriosynangiosis/pial synan- to contact the pial surface of the brain. The prominent left
giosis. Axial CTA image (a) and coronal (c) contrast- superficial temporal artery (arrow) supplying the pial sur-
enhanced MRA image (b) show the left superficial temporal face of the brain is also well depicted on the digital subtrac-
artery (arrows) passing through the small craniotomy defect tion angiogram (c) from an external carotid artery injection
12.1.3 Intracranial Aneurysm Following aneurysm wrapping surgery, the

Wrapping aneurysm will typically appear about the same
size or perhaps slightly smaller, since the main
12.1.3.1 Discussion goal of the procedure is to prevent further expan-
The concept of wrapping aneurysms with strips sion. Although the muscle wrap itself is often
of muscle tissue was first introduced by Cushing inconspicuous, it should not be confused with
as a treatment of ruptured aneurysms. The tem- tumor or other abnormalities, such as hemor-
poralis muscle is an accessible source of the nec- rhage, on imaging (Fig. 12.10). However, the
essary tissue. Alternatively, muslin has also been wrap can resorb and allow aneurysm expansion
used as a wrapping material. Since the 1980s, the and bleeding. Other complications include infec-
practice of wrapping aneurysms has declined in tion or foreign body reaction, if synthetic materi-
popularity. Nevertheless, muscle wrapping is still als are used. Thus, the role of imaging following
used as a last resort for treatment of aneurysms aneurysm wrapping is to evaluate for integrity of
when endovascular stenting/embolization or sur- the wrap, aneurysm expansion or hemorrhage,
gical clipping is not feasible. and abscess or muslinoma formation.
a b
c d
Fig. 12.10 Muscle wrap. The patient had a history of a (encircled). Postoperative axial CT (c) and CTA (d)
growing left P1 segment aneurysm. Although aneurysm images show left temporal craniotomy and interval place-
clipping was planned, muscle wrap was instead performed ment of the muscle wrap, which appears as soft tissue
because clipping posed significant risk of occlusion of the attenuation material surrounding the aneurysm and par-
thalamic perforator or constriction of the left P1 segment. tially filling the left quadrigeminal plate cistern (arrows).
Temporalis muscle was harvested. Preoperative axial CT The aneurysm is slightly less prominent than before
(a) and CTA (b) images demonstrate an aneurysm arising surgery
from the posterosuperior aspect of the left P1 segment
12.1.4 Aneurysm Clipping tently clipped, such as the recurrent artery of

and Hemostatic Ligation Clips Heubner, which can result in caudate infarcts
(Fig. 12.13).
12.1.4.1 Discussion Vasospasm is a significant source of morbidity
Aneurysm clips are used to occlude the neck of in patients with ruptured cerebral aneurysms and
aneurysms in order to prevent or cease hemor- typically manifests 7–10 days after the episode of
rhage due to rupture. These devices are available subarachnoid hemorrhage. Transcranial Doppler
in a variety of shapes and sizes. They consist of a ultrasound is routinely used to assess for cerebral
hinged wire with parallel ends that are straight or vasospasm, but the modality has limited sensitiv-
curved. In the past, aneurysm clips were com- ity and specificity. CTA is also commonly imple-
posed of stainless steel or tungsten. Although mented for the detection of cerebral vasospasm
these materials are biocompatible, they are not following subarachnoid hemorrhage and may
MRI compatible. These clips also produce con- demonstrate multifocal steno-occlusive lesions
siderable beam-hardening artifact that can and areas of hemorrhage (Fig. 12.14). In addi-
obscure surrounding structures. Newer clips are tion, CT perfusion can be performed concurrently
composed of non-ferromagnetic materials, such to provide insight into the extent of cerebral isch-
as titanium, which are MRI compatible and pro- emia resulting from vasospasm. Unfortunately,
duce fewer artifacts on CT. streak artifact from the aneurysm clip can limit
Surgery for aneurysm clipping consists of per- the assessment of the adjacent vasculature.
forming a craniotomy. In addition, variable Ultimately, catheter-based angiography has been
amounts of the anterior clinoid process may be considered to be the historical gold standard to
resected in order to access paraclinoid aneurysms diagnose vasospasm.
(Fig. 12.11). Deeply positioned aneurysms can The incidence of recurrent aneurysms after
be difficult to attain for clipping, which can result complete clipping is approximately is low, but
in aneurysm remnants. Incomplete clipping can this complication can lead to subarachnoid hem-
present as increased hemorrhage shortly after orrhage and requires repeat clipping or endovas-
clipping of ruptured aneurysms, for example, and cular intervention. It is also important to carefully
can be addressed by endovascular embolization search for new aneurysms on postoperative scans,
(Fig. 12.12). Although the brain can be retracted since the annual rate of de novo aneurysm forma-
in order to maximize the field of view and access tion is about 0.9%. These occur on average at
for centrally located aneurysms, vascular injury about 10 years after surgery. Thus, long-term
can result. Likewise, vessels adjacent to aneu- angiographic follow-up is warranted in patients
rysms that have poor visibility can be inadver- with clipped aneurysms.
Fig. 12.11 Anterior clinoid process resection. Coronal

CT image shows absence of the right anterior clinoid pro-
cess and a right curved-tip aneurysm clip
a b
Fig. 12.12 Incomplete aneurysm clipping. Axial CT (b) shows new hemorrhage in the right frontal lobe.
image at initial presentation (a) shows hemorrhage into Digital subtraction angiogram (c) shows residual filling of
the left frontal lobe (arrow) and in the ventricular system the aneurysm sac (encircled) adjacent to the clip. The
due to aneurysm rupture. Axial CT image obtained shortly residual aneurysm sac was then embolized (d)
after anterior communicating artery aneurysm clipping
c d
a b
Fig. 12.13 Adjacent vessel clipping. Axial CT images (a, b) show an anterior communicating artery clip and a recent
right caudate infarct (arrow) due to recurrent artery of Heubner compromise
a b
e f
Fig. 12.14 Vasospasm. Axial CT image (a) obtained 1 artery territories. The CTA (d) and digital subtraction
week after clipping of a ruptured cerebral aneurysm angiography images (e, f) show severe vasospasm in the
shows areas of hypoattenuation in multiple vascular terri- anterior and posterior cerebral vessels, with relatively less
tories and scattered subarachnoid hemorrhage. The MTT pronounced involvement of the middle cerebral artery
(b) and CBF (c) maps show perfusion deficits in the bilat- territories
eral anterior cerebral artery and right posterior cerebral
12.1.5 Vascular Malformation With respect to cavernous malformations,

Surgery developmental venous anomalies are often inci-
dental findings that are not generally considered
When possible, microsurgical resection is the targets for treatment. However, seizure outcome
optimal treatment option for arteriovenous mal- after resection of cavernous malformations is bet-
formations and cavernous malformations. While ter when surrounding hemosiderin-stained brain
the nidus of the arteriovenous malformation rep- also is removed, although this can be challenging
resents the target of resection, the remaining when critical structures are involved (Fig. 12.17).
draining vein can be clipped for hemostasis Head and neck lymphatic malformations are
(Fig. 12.15). However, proximal ligation of the often transspatial and are often not amenable to
supplying arteries alone can make subsequent complete surgical resection. However, when lym-
embolization more difficult and may rapidly lead phatic malformations compromise critical struc-
to revascularization. For inoperable arteriove- tures, such as the airway, partial resection may be
nous malformations that require treatment, ste- performed. MRI is a suitable modality for accu-
reotactic radiosurgery is an alternative. This rate delineation of the residual tumor, which is
treatment essentially results in thrombosis of the useful for planning subsequent additional surgery
malformation. Further, sometimes radiation or sclerotherapy if needed (Fig. 12.18). Obtaining
necrosis can result, which may appear as a up-to-date imaging is particularly relevant since
peripherally enhancing lesion with surrounding the lesions often evolve spontaneously, with new
vasogenic edema (Fig. 12.16). and enlarging components.
a b
Fig 12.15 Arteriovenous malformation resection. The cortical vein (encircled). Postoperative axial CT image (b)
patient has a history of a right frontal lobe arteriovenous shows a Weck clip (arrow) used to ligate the vein during
malformation. Preoperative axial post-contrast surgery
T1-weighted MRI (a) shows an enlarged draining right
a b
c d
Fig 12.16 Arteriovenous malformation stereotactic interval development of extensive vasogenic edema sur-
radiosurgery with radiation necrosis. Pretreatment axial rounding a peripherally enhancing lesion due to radiation
FLAIR (a) and post-contrast T1-weighted (b) MR images necrosis at the site of the arteriovenous malformation,
show a left temporo-occipital nidus. Posttreatment FLAIR which is no longer apparent
(c) and post-contrast T1-weighted (d) MR images show
a b
Fig. 12.17 Residual hemosiderin staining after cavern- cavernous malformation is no longer present, but there is
ous malformation surgery. Preoperative SWI MRI (a) abundant peripheral hemosiderin staining that remains
shows a large right basal ganglia cavernous malformation. (arrow)
Postoperative SWI MRI (b) shows that the bulk of the
a b
Fig. 12.18 Partial resection of lymphatic malformation. MRI (b) shows successful resection of the component of
Preoperative axial T2-weighted MRI (a) shows a trans- the lymphatic malformation that compromised the airway
spatial macrocystic lesion with a component that obstructs but interval appearance of an adjacent cystic component
the upper airway (arrow). Postoperative axial T2-weighted (*)
12.1.6 Microvascular early postoperative period, reversible elevated

Decompression/Jannetta T2 signal and restricted diffusion is often
Procedure observed in the ipsilateral pons after trigeminal
decompression and does not necessarily indicate
12.1.6.1 Discussion infarction. Perhaps the most common complica-
Microvascular decompression can be used to tion of microvascular decompression is recurrent
effectively treat vascular loop syndromes, such symptoms related to suboptimal pledget posi-
as trigeminal neuralgia and glossopharyngeal tioning (Fig. 12.22). For example, in patients
neuralgia (Figs. 12.19, 12.20, and 12.21). The with persistent hemifacial spasm after microvas-
technique essentially consists of interposing cular decompression, residual vascular compres-
Teflon between the affected nerve and the offend- sion is most commonly encountered proximal to
ing vessel. The concept behind this procedure is the pledget, along the attached segment of the
that the Teflon distances and redirects the trans- nerve. Hearing loss is a more unusual complica-
mitted pulsation of the adjacent artery away tion that can result from Teflon migration or the
from the nerve. Teflon is hyperattenuating on CT use of excess Teflon that compresses cranial
and low signal intensity on all MRI sequences. nerve 8 within the internal auditory canal
High- resolution T2-weighted MRI sequences (Fig. 12.23). Granulomas can occasionally form
are particularly useful for analyzing the position in reaction to the presence of Teflon, which
of the pledgets and altered anatomy, which often forms a mass that has low T2 signal and enhances
entails distortion of the nerve course. During the (Fig. 12.24).
a b
Fig. 12.19 Microvascular decompression for trigeminal neuralgia. Axial CT (a) and 3D time-of-flight MRA (b) show
Teflon pledgets in the region of the bilateral trigeminal nerve root entry zones (arrows)
Fig. 12.21 Microvascular decompression for glossopha-

ryngeal neuralgia. Axial CT image shows pledgets
(arrow) used to isolate the right glossopharyngeal nerve
Fig. 12.20 Microvascular decompression for hemifacial root entry zone from surrounding vessels
spasm. Axial CISS MRI shows Teflon (white arrow) inter-
posed between the left facial nerve (arrowhead) and the
enlarged, tortuous basilar artery (black arrow)
a b
d
c
Fig. 12.22 Failed microvascular decompression. The show that the pledget (black arrows) is positioned supe-
patient presented with persistent symptoms of trigeminal rior to the superior cerebellar artery (arrowheads), which
neuralgia following attempted decompression. Coronal directly contacts the left trigeminal nerve (white arrows)
(a, b) and sagittal (c, d) CISS (thin section) MR images
Fig. 12.23 Cochlear nerve compression after microvas-

cular decompression. The patient presented with hearing
loss after microvascular decompression via Teflon injec-
tion for hemifacial spasm. Axial CT image shows a large
amount of Teflon in the left cerebellopontine angle, which
enters the internal auditory canal (arrow), presumably
compressing the cranial nerve 8
a b
Fig. 12.24 Teflon granuloma. Axial T2-weighted MRI post-contrast T1-weighted (c) MR images show corre-
(a) shows a globular hypointense lesion in the right cere- sponding mild enhancement of the lesion (arrows)
bellopontine angle cistern (arrow). Axial pre- (b) and
12.1.7 Carotid Endarterectomy species are the most common causative organ-
isms. Patients typically present with wound
12.1.7.1 Discussion swelling, drainage, and fever. On imaging,
Carotid endarterectomy (CEA) is considered the abscess appears as a fluid collection that abuts the
treatment of choice for symptomatic and asymp- surgical site. Characteristic rim enhancement and
tomatic patients with high-grade carotid artery cellulitis are often present. There may also be
stenosis. In order to appropriately interpret imag- debris, septations, and draining sinus that extends
ing studies obtained following CEA, it is helpful from the operative bed to the incision. Wound
to be familiar with the surgical techniques abscesses usually resolve with antibiotics and
involved. debridement. However, periarterial abscess or
CEA can be performed through an incision patch infection may predispose to dehiscence of
made anterior to the sternocleidomastoid and the suture line, resulting in pseudoaneurysm
ligation of the facial vein in order to expose the formation.
carotid bifurcation and clamping of the carotid Hyperperfusion or reperfusion syndrome is an
artery distal to the endarterectomy. Consequently, unusual complication of carotid endarterectomy
a small hematoma within or adjacent to the ster- or carotid artery stenting, occurring in 0.3–1.2%
nocleidomastoid and mild circumferential nar- of cases. A possible etiology for this condition is
rowing of the carotid artery resulting from clamp impaired cerebrovascular autoregulation.
placement during surgery can be appreciated on Predisposing factors include severe underlying
follow-up CT (Fig. 12.25). These findings are cerebrovascular disease, diabetes mellitus, long-
usually self-limited. standing hypertension, prolonged cross clamping
CEA involves opening the carotid artery, during endarterectomy, and a greater than 100%
removing the plaque and associated endothelium, increase in the degree of reestablished cerebral
and suturing the vessel wall closed with or with- blood flow, which is usually associated with
out an enlargement patch. The patch is usually greater than 90% carotid artery stenosis. Patients
composed of Dacron, which is not readily visible may present with headaches, seizures, focal
on CT, but can appear as a thin hyperechoic mesh neurological deficits, or confusion within several
on ultrasound (Fig. 12.26). Alternatively, the sec- days after surgery. Patients may recover com-
tion of carotid artery that is resected can be pletely if the diagnosis is made promptly.
reconstructed using a saphenous vein graft. This However, in some series, there is a mortality rate
has a distinct patulous or bulbous appearance on of up to 50%. The diagnosis of cerebral hyperper-
imaging (Fig. 12.27). fusion syndrome can be suggested on CT in the
Complications related to CEA include local- proper setting by noting the presence of edema,
ized intimal flap or dissection, reperfusion syn- often in the watershed zones ipsilateral to the side
drome, patch infection, restenosis, cerebral of surgery. On MRI, focal ipsilateral vasogenic
infarction, and cranial nerve injury, usually facial edema is apparent. Diffusion-weighted imaging
and hypoglossal (Figs. 12.28, 12.29, 12.30, and apparent diffusion coefficient maps help con-
12.31, 12.32, and 12.33). firm the presence of vasogenic edema. On MRA,
Wound infection following carotid endarterec- prominent vessels on the affected side may be
tomy occurs in about 2% of cases. Staphylococcus apparent. Similarly, perfusion-weighted imaging
can depict the relative increased flow to the arterectomy with patch angioplasty and the use
affected side. The finding of hemorrhage por- of lipid-lowering pharmaceuticals are associ-
tends a poor prognosis. Imaging can help identify ated with lower rates of restenosis. Risk factors
hyperperfusion syndrome before serious sequelae for restenosis include female gender and renal
result. Differential considerations for the imaging failure. CTA, MRA, and Doppler ultrasound are
appearance of cerebral hyperperfusion syndrome all appropriate for evaluation of suspected
include hypertensive encephalopathy, cyclospo- restenosis or occlusion after carotid endarterec-
rine toxicity, and eclampsia. The lack of restricted tomy. Each of these modalities has advantages
diffusion helps exclude cerebral ischemia. and disadvantages. CTA with reformats, espe-
Recurrent stenosis after carotid endarterec- cially the curved planar reformats, is useful for
tomy occurs at the rate of about 1% per year. studying stenoses. In the setting of carotid end-
This complication is the main limitation of arterectomy with patching, the internal carotid
carotid endarterectomy and predisposes to artery velocities on Doppler ultrasound must be
cerebrovascular ischemia. Acute thrombotic interpreted with caution, since these are nor-
occlusion is much less common and is a poten- mally higher than in the nonoperated counter-
tially devastating complication that can result parts. MRA is best suited for identifying
in cerebral infection. Conventional carotid end- pseudo-occlusions.
Fig. 12.25 Expected carotid endarterectomy early post- Fig. 12.26 Patch endarterectomy ultrasound image
operative changes. Axial contrast CT after recent CEA shows the echogenic Dacron patch (arrow) in the proxi-
demonstrates several foci of air scattered within and adja- mal internal carotid artery
cent to the surgical bed, left sternocleidomastoid swelling,
and edema in the fat planes
Fig. 12.27 Endarterectomy with saphenous vein graft.

3D CT image shows a patulous reconstructed right carotid
bifurcation (*)
a b
Fig. 12.28 Localized intimal flap. Axial (a) and curved planar reformatted (b) CT images show a linear filling defect
(arrows) at the junction of the endarterectomy patch and native carotid artery
a b
Fig. 12.29 Reperfusion syndrome. The patient presented the left cerebral hemisphere watershed zones. CTA MIP
with acute onset of seizures 1 week status post left carotid image (c) shows asymmetrically prominent left middle
endarterectomy . Axial FLAIR MRI (a) and ADC map (b) cerebral artery branches diffusely
show areas of high T2 signal with elevated diffusivity in
Fig. 12.30 Patch infection. The patient presented with

fever, swelling, and purulent drainage from the left carotid
endarterectomy incision site. Axial CT image shows a
rim-enhancing fluid collection (arrow) surrounding the
left carotid artery surgical bed
a b
c d
Fig. 12.31 Carotid artery restenosis. Initial postopera- carotid artery due to low-density plaque at the site of
tive axial CTA image (a) shows a patent proximal left reanastomosis (arrows). Doppler ultrasound (d) confirms
internal carotid artery. Axial (b) and curved planar refor- the presence of high-grade stenosis of the proximal inter-
matted (c) CTA images obtained 6 months later now show nal carotid artery with turbulent flow and velocities sur-
focal high-grade stenosis at the origin of the left internal passing 500 cm/s
Fig. 12.32 Post-endarterectomy carotid artery occlusion (arrow). The diffusion-weighted image (b) shows an asso-
and cerebral infarction. Delayed phase axial CTA image ciated left internal capsule/insula infarction (arrow)
(a) shows occlusion of the CCA at the site of recent CEA
a b
Fig. 12.33 Cranial nerve injury. The patient presented at the expected level of the right hypoglossal nerve
with right cranial nerve XII deficit after right internal (arrow). A subsequent axial CT image (b) shows prolapse
carotid endarterectomy. Initial postoperative axial CT and fatty infiltration of the right hemi-tongue (encircled)
image (a) shows that the endarterectomy was performed
12.1.8 Carotid Body Stimulation 12.1.9 Adjustable Vascular Clamp

Electrical stimulation of the carotid sinus can be Adjustable vascular clamps were first introduced
used to treat systemic hypertension that is unre- in the 1950s for treating carotid system aneu-
sponsive to medical therapy. The phenomenon is rysms. Several varieties of metallic extracranial
effectuated by initiating the baroreceptor reflex carotid vascular clamps have been developed,
and decreasing sympathetic tone. Implanted including the Selverstone, Crutchfield, Poppen-
carotid sinus stimulation systems comprise a Blaylock, Salibi, and Kindt. The principle behind
pulse generator and bilateral perivascular carotid such vascular clamps is to reduce blood flow and
sinus leads (Fig. 12.34). Insertion of these devices to promote clotting of the aneurysm. If collateral
does not appear to cause carotid artery injury or circulation via the circle of Willis is inadequate,
other major side effects. the clamps can be loosened. Gradual, graded
occlusion of the carotids would yield better
results than immediate occlusion. Over time,
however, carotid revascularization can occur
through the clamp and regular follow-up is rec-
ommended. On imaging, the clamps are recog-
nized as rectangle-shaped metallic parts with
central openings of variable sizes (Fig. 12.35).
The lumen distal to the clamp becomes diffusely
narrowed and usually remains as such even after
the clamp is removed.
Fig. 12.34 Carotid body stimulator. Frontal radiograph

shows a Rheos device with bilateral carotid sinus elec-
trodes (arrows) and pulse generator in the right chest sub-
cutaneous tissues (*)
a b
Fig. 12.35 Selverstone clamp. The patient has a history onstrates a right common carotid artery clamp (arrow).
of right carotid body paraganglioma status post radiation Doppler ultrasound (b) shows paucity of flow in the
and right common carotid artery aneurysm status post common carotid artery distal to the clamp
application of vascular clamp. Axial CT image (a) dem-
12.1.10 R
econstruction of the Great
Vessels
Reconstruction of the great vessels may be per-
formed for treatment of steno-occlusive lesions
of congenital aberrations. The surgical maneu-
vers can be complicated and involve reimplanta-
tion of normal vessels onto others (Fig. 12.36)
and/or the use of bypass grafts, such as collagen-
impregnated Dacron and polytetrafluoroethylene
(Figs. 12.37 and 12.38), each with different
imaging appearing. Postoperative MRA, CTA,
Fig. 12.36 Aberrant right subclavian artery reconstruc- Doppler ultrasound, or catheter angiography can
tion. Curved planar reformatted image shows a right axil- be used to evaluate suspected restenosis or occlu-
lary to right common carotid artery bypass (arrow) with sion (Fig. 12.39).
retrograde opacification of the proximal axillary and distal
right subclavian arteries. The proximal right subclavian
artery has been sacrificed. There is also a left common
carotid to subclavian artery bypass and an aortic endo-
graft. There is artifactual duplication of the proximal left
subclavian artery
a b c
Fig. 12.37 Dacron graft. The patient has a history of also end to end. Catheter angiogram (a) shows a widely
symptomatic right common carotid and innominate artery patent Hemashield graft (arrow) and distal vessels (arrow-
occlusive disease. The patient is status post recent aorta to head). CT angiography curved vessel trace (b) and 3D
right common carotid/right subclavian artery bypass from volume rendering (c) show patency of the aorta to right
the ascending aorta utilizing a 10 mm Hemashield graft. common carotid bypass components. The Hemashield
The innominate artery underwent endarterectomy and graft (arrowheads) is a short bulbous segment connected
end-to-end anastomosis with the 10 mm Hemashield, to the stump of the innominate artery (arrows)
which in turn was anastomosed to the ascending aorta,
Fig. 12.38 Debranching of cerebral vessels, right-to-left

common carotid artery crossover bypass, and left com-
mon carotid artery transposition to the left subclavian
artery for treatment of thoracoabdominal aortic dissec-
tion. The 3D CTA reformatted image shows the cross-
over polytetrafluoroethylene bypass graft (arrow)
a b
Fig. 12.39 Thrombosed graft. The patient is status post (arrow), which is suggestive of thrombosis. There is also
aortic repair and subclavian injury followed by placement poor opacification of the distal right common carotid
of a right carotid to axillary bypass graft with 6 mm exter- artery. Doppler ultrasound (b) of the distal graft anasto-
nally supported polytetrafluoroethylene. Axial CTA image mosis site reveals paucity of flow through the graft (GFT)
(a) shows lack of enhancement within the artificial graft
12.2 Endovascular Surgery to vascular assessment. Most intracranial endo-

vascular devices create relatively less artifact on
12.2.1 General Imaging MRI compared to CT. For example, embolic
Considerations coils used in aneurysm are predominantly made
Following Endovascular of platinum. These have only mild susceptibility
Cerebrovascular Procedures effect on MRI/MRA. Indeed, MRA is an effec-
tive means to assess small degrees of aneurysm
Endovascular cerebrovascular procedures recurrence following coil embolization
include endovascular reconstruction or decon- (Fig. 12.40). Most intracranial stents have rela-
struction for cerebrovascular occlusive disease tively low mass, but still produce susceptibility
or active bleeding using stents or embolic mate- artifacts on MRI, giving the corresponding ves-
rial; embolization of tumors, aneurysms, or vas- sel’s intraluminal diameter a false appearance of
cular malformations either preoperatively or for being narrowed (Fig. 12.41). Liquid embolic
treatment; and mechanical or chemical throm- agents, such as Onyx, generally produce a signal
bolysis for acute ischemic stroke or vasospasm. void on MRA, T1-, and T2-weighted MRI with-
Materials that are typically used during neuroen- out s ignificant obscuration of adjacent vascula-
dovascular procedures include metal containing ture (Fig. 12.42). However, Onyx HD500 used
devices, such as coils, plugs, and stents, liquid for treating aneurysms is associated with more
embolic agents, balloons, and particles. Certain susceptibility effect compared to Onyx used for
metals contained in some of these endovascular arteriovenous malformation embolization,
treatment modalities create substantial streak which can overestimate the degree of stenosis on
artifact on CT, rendering imaging less sensitive MRA (Fig. 12.43).
a b
c d
e f
Fig. 12.40 Embolic coil occlusion. MRA before (a) and following aneurysm embolization demonstrates substan-
after (b, c) the anterior communicating artery aneurysm tial streak artifact which precludes evaluation for early
(arrows) demonstrate complete occlusion of the aneu- recurrence as opposed to the MRA, which has negligible
rysm, as demonstrated on pre- and post-embolization artifact, allowing for satisfactory evaluation of potential
digital subtraction arteriograms (d, e). Axial CT image (f) recurrence
a b
Fig. 12.41 Stents. Unsubtracted angiographic image (a) MRA following the procedure (b) demonstrates occlusion
following Y-shaped stent-assisted coiling of a basilar tip of the aneurysm with artifact giving a false impression of
aneurysm demonstrates the proximal and distal markers stenosis along the stent despite lack of evidence for this on
(arrows) of the stents as well as coils within the aneurysm. digital subtraction angiography (c)
a b
c d
Fig. 12.42 Onyx liquid embolization. Time-of-flight cant artifact on CT preventing adequate evaluation,
MRA and CT before (a, b) and after (c, d) embolization of whereas time-of-flight MRA has the ability to detect a
a posterior cingulate gyrus arteriovenous malformation residual component of the arteriovenous malformation
using Onyx. Note that the embolic material creates signifi- (arrow)
a b
Fig. 12.43 Onyx HD500. Digital subtraction angiogra- patency of adjacent vessels, while susceptibility artifact
phy (a) after embolization of a giant aneurysm of the left on MRA (b) obscures the surrounding vessels (encircled)
internal carotid artery cavernous segment demonstrates
12.2.2 Endovascular Treatment untreatable aneurysms. The devices provide

for Aneurysms 30–35% metal coverage of the inner surface of
the target vessel with a pore size of 0.02–
Endovascular occlusion of cerebral aneurysms 0.05 mm. The tube mesh implants are believed
can be achieved via coil embolization, liquid to achieve their results via functional recon-
embolic embolization, or flow-diverting stents struction of the parent artery with rerouting of
(Figs. 12.40, 12.41, 12.43, and 12.44). The blood flow away from the aneurysm while pre-
number of coils utilized depends on the size of serving flow to branch vessels. Although aneu-
the lesion and the type of coil. For example, rysm opacification is often observed on
fewer hydrogel coils are required than bare angiography during the early postoperative
metal coils for comparable aneurysm sizes. period, complete occlusion is achieved in the
Stents are sometimes used to support the coils, majority of treated aneurysms by 6 months.
especially for wide-necked and fusiform aneu- Protocols for follow-up imaging after aneurysm
rysms. Flow- diverting stents, such as the coil embolization vary among institutions and
Pipeline and Silk devices, are an option for include either conventional angiography, CTA,
treating large, wide- necked, or otherwise MRA, or a combination of these.
a b
Fig. 12.44 Flow-diverting stent. Preoperative CTA image Pipeline stent insertion (b) shows residual filling of the aneu-
(a) shows a large, wide-necked left supraclinoid internal rysm (arrow). CTA image obtained 12 months after Pipeline
carotid artery aneurysm (*). CTA obtained at 2 months after stent insertion (c) shows obliteration of the aneurysm
12.2.3 Endovascular Embolization artifact on CT and may require catheter angiog-

of Arteriovenous raphy for more definitive assessment. On the
Malformations and Fistulas other hand, particles, such as PVA, used for
embolization are not directly apparent on imag-
Liquid embolization agents, such as n-butyl cya- ing. In the past, arteriovenous malformations
noacrylate, Onyx, and particles, such as polyvi- were sometimes treated with Silastic beads,
nyl alcohol (PVA), are commonly used to treat which appear as tiny spherical hyperattenuating
arteriovenous malformations and fistulas, some- structures measuring 1–5 mm in diameter
times in conjunction with coils (Fig. 12.45). (Fig. 12.46). Clinical improvement could be
Liquid embolic agents that are not inherently achieved even without occlusion of symptomatic
radiopaque are often mixed with tantalum pow- arteriovenous malformation due to reduction of
der in order to improve visibility during fluoros- cerebral steal phenomenon. Furthermore,
copy. The embolic agent forms casts of the remaining portions of the malformation can
embolized vessel, which is visible on CT due to sometimes spontaneously thrombose after treat-
the tantalum powder and creates a signal void on ment and not require further intervention.
MRI. The presence of tantalum powder within Otherwise, surgical resection is often performed
the liquid agents is responsible for the streak after partial embolization.
a b
Fig. 12.45 Arteriovenous malformation embolization. images following the embolization display streak artifact
Digital subtraction AP arteriograms of a right frontal lobe related to the tantalum powder and coils used (c) and
arteriovenous malformation before (a) and after (b) thrombosis of a large intranidal venous structure (d). The
embolization using a mixture of n-butyl cyanoacrylate, AVM did not recur following embolization
Lipiodol, and tantalum powder, as well as coils. Axial CT
c d
Fig. 12.46 Silastic bead embolization. Axial MIP image

shows spherical hyperattenuating foci within an arteriove-
nous malformation treated many years before
12.2.4 Endovascular Deconstructive vascular detachable balloons have been used to

Treatment for Vessel Sacrifice treat intracranial aneurysms, often in conjunction
with coil embolization. Detachable balloons are
Vessel sacrifice is an accepted method for treat- generally used to achieve permanent occlusion.
ment of cerebrovascular lesions including carotid Balloons are usually composed of silicone or
blowout, aneurysms, dissections, epistaxis, dis- latex and can be filled with contrast material in
section, or preoperatively to facilitate tumor order to increase conspicuity on imaging
resection. Occlusive materials may include but (Fig. 12.47). Vascular plugs can be used success-
are not limited to detachable balloons, coils, par- fully for permanent occlusion of head and neck
ticles, plugs, or liquid embolic material. When vessels. Amplatzer vascular plugs, for example,
these involve the carotid or vertebral artery, a test are composed of self-expandable nitinol mesh
occlusion often precedes the vessel sacrifice (bal- with one or more lobes and radiopaque platinum
loon test occlusion). Post-procedural findings markers at each end (Fig. 12.48). Major compli-
include identification of the embolic material cations are uncommon and include cerebral
within the sacrificed vessel. In particular, intra- infarction, blindness, and cranial nerve palsies.
a b
Fig. 12.47 Detachable balloons. CT image (a) shows multiple Silastic balloons within the right internal carotid artery
(arrows). The balloons appear as a high T2 signal (b) and low T1 signal (c) filling defects in the carotid artery (arrows)
12.2.5 Preoperative Embolization

of Neoplasms
Preoperative embolization of intracranial vascu-

lar neoplasms typically uses particles and
occasionally liquid embolic material or coils with
the aim to occlude vessels within the tumor or
immediately proximal to the vascular neoplasm.
Since such patients often go to surgery shortly
after the embolization, they do not undergo imag-
ing unless symptomatic or for presurgical plan-
ning. Possible post-procedural complications
include thromboembolic events and intratumoral
hemorrhage as well as parent vessel dissection.
However, the effects of particle embolization can
Fig. 12.48 Vascular plugs. Lateral radiograph (a) and be apparent. For example, absence of a contrast
curved planar reformatted CTA image (b) show an
blush or enhancement due to tumor necrosis indi-
Amplatzer plugs (arrows) within the right common
carotid artery cates successful treatment (Fig. 12.49).
Furthermore, restricted diffusion can appear in
the embolized tumors due to infarction.
a b
c d
Fig. 12.49 Tumor embolization. The left frontal meningi- feeding vessels, there is no longer a tumor blush (c). Post-
oma underwent PVA particle embolization prior to surgical embolization contrast-enhanced T1-weighted MRI (d) and
resection. Pre-embolization DSA image (a) shows a strong ADC map (e) images obtained within 24 h of the procedure
tumor blush. The corresponding CT with contrast (b) shows show a large area of nonenhancement with corresponding
a large, early homogeneously enhancing left frontal extra- restricted diffusion within the meningioma (*), which repre-
axial mass. Following microparticle embolization of the sents embolization-induced tumor infarction
12.2.6 Endovascular Sclerotherapy lesion. Imaging following sclerotherapy for a low-

for Head and Neck Lymphatic flow vascular malformation of the head and neck is
Malformations used to identify lesional shrinkage, decreased
enhancement, and intralesional fibrosis (Fig. 12.50).
Percutaneous sclerotherapy is a minimally invasive MRI is a suitable modality for evaluating treatment
means to treat low-flow vascular malformations in response following sclerotherapy in the deep soft
the head and neck in which sclerosing agents such tissues, due to the lack of ionizing radiation, excel-
as bleomycin, sodium tetradecyl sulfate, and alco- lent soft tissue contrast resolution, and multiplanar
hol, among other agents are infused directly into the
a b
c d
Fig. 12.50 Lymphatic malformation sclerotherapy. therapy using sodium tetradecyl sulfate demonstrate invo-
STIR and post-contrast fat-suppressed T1-weighted MRI lution of the right facial lymphatic malformation
images before (a, b) and after (c, d) percutaneous sclero-
capabilities. MRI is also useful for planning subse- (Fig. 12.52). Following successful embolec-
quent treatments, if needed. tomy or thrombolysis, patients are at risk for
reperfusion hemorrhage, which occurs in an
estimated 5–10% of patients. Edema due to
12.2.7 Endovascular Reconstructive infarction peaks at approximately 72 h follow-
Treatment for Acute Ischemic ing the procedure, whereas edema due to hem-
Stroke Using Intra-arterial orrhage may take a week to reach its peak.
Thrombolysis or Patients are at risk for herniation during this
Embolectomy time. Imaging can be used to evaluate the extent
of infarction, reperfusion edema, and hemor-
Various catheter-based devices and techniques rhage. Potential complications from embolec-
have been devised for clot removal from the tomy that can be visible on cerebrovascular
cerebral arteries. Some of these include the use imaging include intraprocedural hemorrhage,
of a snare, the alligator retrieval system, the vessel rupture, and vessel dissection. Potentially
Phenox clot retriever, the Merci catheter, and confounding is the frequently encountered
the Penumbra and stent retrievers among others extravasation of contrast into areas where there
(Fig. 12.51). Angiographic imaging can confirm has been breakdown of the blood-brain barrier.
successful recanalization following mechanical Residual contrast staining from the procedure
thrombectomy or intra-arterial thrombolysis due to blood-brain barrier leakage in infarcted
a b
Fig. 12.51 Mechanical thrombectomy devices. Angiographic images of the Merci retriever device (a); Penumbra
device, with catheter tip (arrow) and separator tip (arrowhead) (b); and Solitaire stent retriever device (c)
a b
Fig. 12.52 Mechanical thrombectomy. Pre-procedure image (b) shows interval patency of the left M1 with mini-
axial CTA MIP image (a) shows complete occlusion of mal residual irregularity
the left distal M1 (encircled). Post-procedure CTA MIP
a b
Fig. 12.53 Retained contrast in infarcted parenchyma. hyperattenuation has nearly cleared and instead there is
Axial CT image obtained 18 h following embolectomy (a) hypoattenuation due to edema from infarction in the left
shows hyperattenuation within the left basal ganglia. basal ganglia
Axial CT image obtained 24 h later (b) shows that the
a b
Fig. 12.54 Retained contrast and dual energy CT. Axial insula (arrow). The corresponding iodine overlay image
(a) CT image at 120 keV obtained after mechanical (b) confirms the presence of contrast (Courtesy of Rajiv
thrombectomy shows a hyperattenuating area in the right Gupta, M.D., Ph.D.)
parenchyma can resemble hemorrhagic trans- agulated in the first 24 h. The intent of the treatment
formation (Fig. 12.53). Dual energy CT with is not to achieve 100% luminal diameter, but to
iodine overlay maps can help distinguish the achieve adequate improvement in flow. Therefore,
two possibilities if necessary (Fig. 12.54). comparison of posttreatment luminal diameter to
pretreatment luminal diameter is appropriate.
Postoperative imaging can be used to determine if
12.2.8 Endovascular Reconstruction the vessel diameter improves and if it does, that it
for Intracranial is sustained and associated with improvement in
Cerebrovascular Steno- cerebrovascular perfusion. Typical posttreatment
occlusive Lesions imaging may include MR angiography, conven-
tional angiography, and CT angiography.
Treatment for intracranial cerebrovascular occlu- Conventional angiography is the gold-standard
sive disease includes angioplasty with stent place- imaging assessment for such lesions. Otherwise,
ment or angioplasty without stent placement. MR angiography, CT angiography, MR perfusion,
These patients receive antiplatelet treatment fol- SPECT, and CT perfusion are powerful noninva-
lowing the procedure and are usually also antico- sive means to assess posttreatment effects. In par-
a b
Fig. 12.55 Stent-assisted angioplasty. Pretreatment 3D CTA image (a) shows critical stenosis at the right distal vertebral
artery (arrow). Posttreatment 3D CT image (b) shows interval patency of the vessel with a stent in position (encircled)
ticular, 3D reconstructions can provide as helpful 12.2.10 Endovascular Stent

overview of the vessels (Fig. 12.55). The standard Reconstructive Treatment
method for characterizing intracranial stenosis is for Extracranial
based on the WASID criteria, whereby percent ste- Cerebrovascular Occlusive
nosis = [(1 − (vessel diameter at the stenosis/nor- Disease
mal vessel diameter))] × 100%.
Carotid artery stenting is mainly reserved for patients
with symptomatic carotid stenosis greater than 50%
12.2.9 Angioplasty and Intra-arterial or asymptomatic stenosis greater than 70% by
Spasmolysis for Vasospasm NASCET criteria who are otherwise poor surgical
candidates for endarterectomy. The procedure con-
For symptomatic vasospasm refractory to hemo- sists of endovascular placement of a flexible, self-
dynamic therapy, endovascular techniques, such expanding stent following angioplasty of the affected
as balloon angioplasty and intra-arterial spasmol- vessel and use of a distal protection device. Imaging
ysis with papaverine or nimodipine, may be con- following stent placement may be performed in
sidered in order to improve cerebral perfusion. order to determine if the luminal diameter following
Following successful angioplasty or spasmolysis angioplasty and stent placement has improved. The
for vasospasm, imaging with CTA or MRA may standard methods for assessing stenosis at the
be used to characterize the extent of infarction, carotid bifurcation use NASCET or ECAS criteria.
improvement in cerebral perfusion, and luminal Methods used to assess luminal diameter include
diameter of the affected vessels (Fig. 12.56). carotid duplex ultrasound conventional angiogra-
Otherwise, transcranial Doppler ultrasound is a phy, MRA, and CTA (Fig. 12.57). The morphology
convenient modality for assessing the degree of of the stent can vary considerably depending on the
vasospasm due to its availability at the bedside. design and amount of atherosclerotic disease in the
vessel. For example, stents can be straight or tapered.
Tapered stents can have a conical design, in which
a b
Fig. 12.56 Spasmolysis. This patient developed symp- cerebral arteries with intra-arterial pharmacologic spas-
tomatic vasospasm involving the left middle cerebral molysis using calcium channel blockers, there was signifi-
artery after aneurysm clipping, which was documented on cant and sustained improvement in the diameter of the
CTA (a). Following angioplasty of the proximal anterior anterior cerebral arteries (b)
a b
c d
Fig. 12.57 Cervical carotid stenting. Digital subtraction before (a, b) with resolution of the stenosis immediately
angiography (DSA) color duplex ultrasound before and after (c) and 1 month following stent placement (d).
after angioplasty and stent placement for high-grade ste- Carotid duplex ultrasound is a noninvasive means to eval-
nosis in a patient who had symptomatic stenosis. Both uate carotid stent placement for carotid bifurcation
DSA and color duplex arteriography demonstrate the ste- stenosis
nosis with high flow velocities on the carotid duplex scan
there is gradual decrease in caliber of the stent from 12.2.11 Endovascular

proximal to distal, versus shoulder-tapered, in which Reconstructive Treatment
there is an abrupt change in caliber in the midportion for Active Extracranial
of the stent. Atherosclerotic plaque can produce a Hemorrhage or
waist in the stent. A residual waist of less than 20% Pseudoaneurysm
of the lumen diameter is considered acceptable.
Following the deployment of stents for reconstruc- Endovascular reconstructive treatment is cur-
tion, there are expected artifacts that affect the imag- rently performed using covered stents or a com-
ing appearance of the treated vessel for extracranial bination of stents and embolic material. Covered
carotid disease or carotid blowout disease. stents are deployed in circumstances where a
a c
Fig. 12.58 Covered stent. CTA (a) shows a pseudoaneu- the aneurysm is no longer identified on follow-up carotid
rysm along the midportion of the right common carotid duplex ultrasound (b) and CT angiography (c)
artery (arrow). Following placement of a covered stent,
patient has had a carotid blowout due to open oping blood flow around the stent or endoleak,
communication of the parent artery with the air- which may result in rehemorrhage, as well as
way or skin surface (Fig. 12.58) and it is felt that infection in the form of septic emboli with brain
the patient would be unable to tolerate parent abscess formation.
vessel sacrifice without high risk for neurologic
deficit. Posttreatment imaging may be performed
in order to assess luminal patency and intracra-
nial events. Methods used to assess luminal
diameter include carotid duplex ultrasound con-
ventional angiography, MRA, and CTA. Patients
who receive covered stents are at risk for devel-
a b
Fig. 12.59 Endovascular cerebral venous thrombolysis. later despite anticoagulation (c). The patient underwent
The MR venogram (a) shows thrombosis of the internal embolectomy using penumbra device, and recanalization
cerebral veins, straight sinus, and basal vein of Rosenthal. of the previously thrombosed vessels (arrows) was
The T2-FLAIR MRI (b) demonstrates associated edema achieved, as demonstrated on the follow-up CT venogra-
within the bilateral thalami and to a lesser extent in the phy (d) and the edema regressed on the T2- FLAIR MRI
basal ganglia. The patient deteriorated and the degree of (e). Susceptibility-weighted imaging (f) demonstrates a
edema worsened as depicted on the T2- FLAIR MRI 24 h few microhemorrhages within the thalami
e f
Fig. 12.60 Transverse sinus stent. Axial CT image

shows a stent in the right transverse sinus
12.2.12 Endovascular Treatment idiopathic intracranial hypertension. Stenting

for Intracranial Venous is most appropriate if a pressure gradient of
Stenosis and Occlusion more than 10 mmHg exists across a stenosis.
Either self-expandable or balloon-expandable
Endovascular treatment for symptomatic inter- stents can be used. The most c ommon compli-
nal cerebral vein thrombosis or dural sinus cations include in-stent thrombosis, headache,
thrombosis may include fibrinolytic infusion and hearing loss.
and mechanical embolectomy. Imaging typi-
cally demonstrates resolution of cerebral
edema following successful therapy 12.2.13 Complications Related
(Fig. 12.59). Alternatively, venous sinus stent- to Endovascular Procedures
ing can be performed to treat stenoses that are
unresponsive to medical therapy, most com- Access Site Complications. Non-neurologic
monly in the transverse sinus (Fig. 12.60). The complications related to head and neck endovas-
procedure can be performed for restoring cular interventions are uncommon, occurring in
patency of transverse sinuses in patients with 0.14% of cases who undergo femoral artery
Fig. 12.61 Access site hemorrhage. The patient experi-

enced dropping hematocrit after carotid artery stenting.
Axial CTA image showsright groin and pelvic hemor-
rhage and a right femoral arterypseudoaneurysm (arrow)
a b
c
d
Fig. 12.62 Hyperperfusion syndrome. The initial digital cedure, as well as right hemiparesis and aphasia.
subtraction arteriography (a) demonstrates a long- Susceptibility-weighted imaging (c) demonstrates punc-
segment high-grade stenosis (arrow). Following the stent tate left cerebral hemisphere microhemorrhages (arrows).
placement, the left internal carotid artery dilated to its nor- CT perfusion cerebral blood flow map (d) demonstrates
mal diameter (b). Although the patient was doing well relatively higher blood flow to the left hemisphere
initially, the patient experiences seizure following the pro- (encircled)
access. Such complications include femoral Cerebral Hyperperfusion Syndrome. Cerebral

abscess, occlusions of the femoral artery with leg hyperperfusion syndrome classically occurs
ischemia, dissection and pseudoaneurysm forma- within the first few days following carotid artery
tion, retroperitoneal hemorrhage requiring trans- revascularization for severe stenosis. Patients
fusion, or a combination of these. CT/CTA is a present with severe headache or neurologic defi-
reasonable option for evaluating patients with cits. It is often accompanied by seizures and may
suspect vascular compromise and hemorrhage in result in intracranial hemorrhage. In general,
the emergent setting (Fig. 12.61). patients with severe stenosis have chronic maxi-
mal dilation of the intracranial vasculature, which
a b
Fig. 12.63 Intraprocedural aneurysm rupture. Digital deployment of a balloon and continued embolization
subtraction angiography (a) shows aneurysm rupture as using coils. CT obtained immediately following the pro-
evidenced by contrast extruding beyond the confines of cedure (b) demonstrates scattered subarachnoid hemor-
the aneurysm (arrow), which was treated by immediate rhage, which was not present before the procedure
a b
Fig. 12.64 Intraparenchymal hemorrhage due to antico- treatment during the procedure, and 16 h following embo-
agulation. Digital subtraction arteriogram (a) shows lization, the patient suddenly deteriorated due to a remote
embolization of a right middle cerebral artery aneurysm. hemorrhage in the cerebellum, as shown on CT (b)
The patient was on anticoagulation and double antiplatelet
a b
Fig. 12.65 Intracranial hemorrhage complicating flow The coronal CT image (a) shows a left intracranial artery
diversion. The patient presented with right-sided weak- Pipeline stent (arrow). The axial CTA image (b) shows a
ness after treatment of a left cavernous carotid aneurysm. large left frontoparietal hematoma with a hematocrit level
does not immediately reverse at the time of reper- ance and altered Windkessel effect. The intrapa-
fusion by stenting. This results in a hyperperfu- renchymal hemorrhages in such cases can be
sion phenomenon. Imaging can be performed to large and contain hematocrit levels (Fig 12.65),
evaluate for associated hemorrhage, and the diag- since the patients are typically anticoagulated.
nosis is supported by the finding of increased per- CT tends to be the modality of choice for evaluat-
fusion ipsilateral to the stented vessel (Fig. 12.62). ing post-procedure hemorrhage, even if metal
- artifact may degrade the images in some cases.
Intracranial Hemorrhage. Hemorrhagic com- Stent Steno-occlusive Disease. Patency of the

plications may include intraprocedural aneurysm stent can be evaluated using MRA, CTA, or
rupture (Fig. 12.63), intraparenchymal hemor- Doppler ultrasound. Velocity criteria for
rhage related to anticoagulation and/or antiplate- extracranial internal carotid artery stents have

let treatment (Fig. 12.64), and hyperperfusion been proposed as follows:
syndrome with revascularization procedures, as
mentioned before. Furthermore, delayed ipsilat-
eral intraparenchymal hemorrhage has been
described as a potential complication following
flow diversion of anterior circulation aneurysms,
perhaps due to decreased arterial wall compli-
Fig. 12.66 Intimal hyperplasia. Curved planar reformat-

ted CTA image shows thin, low attenuation material
within the stent lumen
a b
Fig. 12.67 Stent stenosis. Coronal CTA image (a) shows a filling defect (arrow) in the distal portion of the left MCA
stent. Catheter angiography 3D reconstruction (b) confirms a severe, near-critical stenosis in the stent (arrow)
Fig. 12.68 Stent occlusion. Delayed curved planar refor-

matted CTA image shows complete lack of opacification
of the left internal carotid stent
• Residual stenosis ≥20%: peak systolic veloc- Intimal hyperplasia is the process of endo-
ity ≥150 cm/s and ICA/CCA ratio ≥2.15 thelial regrowth after injury and can occur
• In-stent restenosis ≥50%: peak systolic veloc- within the lumen of stents, usually with a
ity ≥220 cm/s and ICA/CCA ratio ≥2.7 thickness of 1 or 2 mm. However, intimal
• In-stent restenosis ≥80%: peak systolic veloc- hyperplasia is sometimes more extensive and
ity 340 cm/s and ICA/CCA ratio ≥4.15 can lead to hemodynamically significant ste-
nosis. On ultrasound, intimal hyperplasia is
typically homogeneously hypoechoic, and on
Fig. 12.70 Stent compression and fracture. Coronal CT

Fig. 12.69 Stent kink. CT curved planar reformat shows MIP image demonstrates deformity and a gap between
a focal angulation (arrow) in the lateral aspect of this fragments of a subclavian artery stent at the thoracic outlet
curved supraclinoid internal carotid artery stent, which is (encircled). The ends of the stent adjacent to the fracture
otherwise intact are compressed
CT it appears as mural hypoattenuation sensitive and allows further treatment, such as

(Fig. 12.66). angioplasty, to be performed.
Significant stent restenosis is a fairly common Stent occlusion is a serious complication that
complication, occurring in about 15% of cases can result from in-stent thrombosis. As before,
within several months of the procedure. several modalities can be used to evaluate this
Restenosis is more likely with self-expandable complication. CTA with delayed imaging can be
stents than balloon-expandable stents. CTA can helpful for differentiating high-grade stenosis
demonstrate filling defects in the lumen of the versus occlusion (Fig. 12.68).
stent (Fig. 12.67). Catheter angioplasty is more
a b
Fig. 12.71 Residual aneurysm. Time-of-flight MRA source (a) and MIP (b) images show flow into a small residual
anterior communicating artery aneurysm neck (arrows) after coil embolization
a b
Fig. 12.72 Coil compaction. Pre-procedure CT angiog- the basilar tip aneurysm with metal coils. Follow-up digi-
raphy curved planar reformatted image (a) shows a large tal subtraction angiogram (c) shows interval coil compac-
basilar tip aneurysm (*). Immediate post-embolization tion with substantial aneurysm filling (arrow)
catheter angiogram (b) shows near-complete occlusion of
Mechanical Stent Failure. Mechanical stent fail- the fractured device. Anatomy of the stented ves-
ure can manifest as indentation, compression, sel plays an important role in stent deformity,
kinking, and/or fracture (Figs. 12.69 and 12.70). such that this phenomenon tends to occur along
Deformed stents can lead to vascular occlusion curvatures, such as in the carotid siphon region.
and/or embolization, which can be depicted on Flat-panel CT is reported to be more sensitive for
Doppler ultrasound and/or angiography imaging. depicting stent deformities than is digital subtrac-
This complication is less likely with self-expand- tion angiography.
ing stents than with balloon-expanding stents.
Treatment consists of inserting smaller caliber Residual and Recurrent Aneurysms. It can be
stents into the damaged stent lumen or retrieving challenging or even risky to completely obliterate
a b
Fig. 12.73 Silent thromboembolic events. There are multiple foci of restricted diffusion shown on DWI (a) ADC map
(b) obtained after recent coiling of a ruptured 6 mm anterior communicating artery aneurysm
Fig. 12.74 Nontarget embolization. Sagittal CT image

shows a coil in the distal anterior cerebral artery (arrow)
from proximal stent-assisted aneurysm coiling
aneurysms via coil embolization, particularly in stability of the aneurysm (Fig. 12.71). On the
cases of aneurysm rupture. However, the pres- other hand, coil compaction is deemed to be the
ence of a small residual neck does not necessarily most common cause of aneurysm recurrence
warrant further intervention, unless there is after embolization and is a process whereby
growth of the aneurysm. Thus, surveillance imag- aneurysm coil mass volume decreases over time
ing via MRA is typically performed to ensure and is more likely to occur after embolization of
a b
Fig. 12.75 Coil prolapse. Digital subtraction angiogram into the lumen of the adjacent vessel (ICAs). The pro-
(a) and 3D angiogram in a different patient (b) depict lapsed coils were not significantly flow limiting
loops of coils (encircled) that project from the coil masses
a b
Fig. 12.76 Coil malpositioning requiring removal. vessel. Digital subtraction angiogram (b) shows attempted
Reformatted CT image (a) shows a coil mass within a coil retrieval using the Merci device, which is wrapped
basilar tip aneurysm and a coil that extends inferiorly into around the coil
the left vertebral artery (arrow), thereby occluding the
ruptured aneurysms as well. This process can be being treated (Fig. 12.73). Distal migration of
observed on serial imaging in which there is stents or coils can occur during or after the
enlargement of the aneurysm sac from baseline intervention and can also be associated with
(Fig 12.72). morbidity. However, immediate removal of the
devices is often feasible and effective before
Embolic Phenomena. Silent thromboembolic clots form. Furthermore, anticoagulation can be
events associated with neurointerventional pro- helpful in maintaining blood flow. Beyond the
cedures are a relatively common occurrence, immediate intraprocedural period, imaging via
despite meticulous technique and systemic CTA can help localize the migrated hardware
anticoagulation. This can occur due to the for- and assess for associated complications
mation of thrombus associated with the devices (Fig. 12.74).
used during the procedure or the introduction of
intravascular air. Nevertheless, significant clini- Coil Malpositioning/Prolapse. Coils in exces-
cal consequences are rare. The lesions are typi- sively packed aneurysms can potentially prolapse
cally small, often multifocal, and usually through the aneurysms’ neck into the parent ves-
localize to the vascular territory of the vessel sels, particularly in cases of wide aneurysm necks
Fig. 12.77 Hydrocephalus after embolization. Coronal

CT image shows disproportionate dilatation of the lateral
ventricles following unruptured anterior communicating
aneurysm embolization
a b
Fig. 12.78 Retained microcatheter. The patient under- tenuating due to the presence of concentrated embolic
went left temporal arteriovenous malformation emboliza- material retained in the lumen. The microcatheter (arrow)
tion. Axial CT image (a) shows the serpiginous course of is hypointense on the T2-weighted MRI (b)
the intravascular catheter (arrow), which appears hyperat-
a b
Fig. 12.79 Retained snare. The patient is status post coil that further manipulation of this adherent fragment might
embolization of a left superior cerebellar artery aneurysm have catastrophic consequences. Frontal spot image (a) at
with coil migration into the basilar artery and iatrogenic the end of the procedure shows a retained fragment of the
retained distal fragment of snare device within the distal snare device (arrow) in the basilar artery, adjacent to the
basilar artery while attempting to retrieve the malposi- coils projecting into the basilar artery. Coronal (b) CTA
tioned coil. These materials were left in situ and the image shows the fractured snare (arrow) and embolization
patient is treated with dual antiplatelet treatment to permit coils remain position, but the basilar artery and distal
endothelialization until future follow-up, due to concern branches are patent
and partially thrombosed aneurysms. Prolapse of how related to an exaggerated inflammatory

only a few coils is not necessarily flow limiting response during aneurysm healing. MRI or CT
(Fig. 12.75). However, extension of greater can readily depict post-coiling hydrocephalus
lengths of coils into the parent vessels can predis- (Fig 12.77).
pose to significant thromboembolic events and
may warrant removal (Fig. 12.76). A variety of Retained Hardware. A potential complication of
devices can be used to remove the migrated coils, endovascular procedures involving embolization
such as microsnares and the Merci retriever. material is entrapment of the microcatheter.
Imaging may be obtained to evaluate the extent
Hydrocephalus After Coil Embolization. and location of the entrapped microcatheter,
Hydrocephalus commonly results from subarach- which appears as hyperattenuating on CT and
noid and intraventricular hemorrhage from rup- low signal intensity on MRI due to the retained
tured aneurysms. Hydrocephalus can also occur embolization material (Fig. 12.78). If endovascu-
following embolization of unruptured aneurysms, lar attempts fail to remove the microcatheters,
particularly with hydrogel coils. The mechanism these can be removed via microsurgical retrieval.
by which hydrogel coils may induce hydrocepha- Another more unusual situation is fragmentation
lus is not well understood. However, one possible and retention of a snare used to retrieve malposi-
etiology is that hydrogel coils undergo progres- tioned coils (Fig. 12.79). Thus, it is useful to be
sive expansion once exposed to the physiological familiar with the imaging appearance of various
environment and increase overall aneurysm fill- devices used, in case such situations are encoun-
ing. Another possibility is that it may be some- tered in practice.
Further Reading Superficial siderosis of the CNS: MR diagnosis and clini-

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Index
A nerve root clumping, 591

ABIs. See Auditory brainstem implants (ABIs) postoperative, 591–592
Absorbable hemostatic agents Artificial bypass grafts
description, 149 carotid-axillary/carotid-subclavian artery bypass,
gelatin foam, 149, 151 653, 654
gelatin-thrombin matrix, 149, 152 Dacron graft, 646, 654
oxidized regenerated cellulose, 149, 150 thrombosed polytetrafluoroethylene graft, 653, 655
retained cottonoid, 149, 153 Atresiaplasty
Surgicel, 149, 150 preoperative axial, 357, 362
surgifoam, 149, 151 recurrent cholesteatoma, 357, 358
types, 149 Auditory brainstem implants (ABIs)
Adjacent segment disease, 601 cochlear implants, 407
Amygdalohippocampectomy, 249–250 neuro fibromatosis type 2, 407
Aneurysm clips suboptimal production, 407
anterior clinoid process resection, 636, 637 Auricular reconstruction
description, 636 porous polyethylene, 355
recurrence, 636, 656 rib graft, 354
right supraclinoid, 683 Auriculectomy
straight-tip, 636, 673 auricular reconstruction, rib graft, 354, 355
Anterior craniofacial resection flap reconstruction, 396
bone graft reconstruction, 311, 314–315 Autocranioplasty
cerebral infarction, 311, 315 bone flaps, 139
encephalocele, 312, 317 frontal radiograph and axial CT image, 139
intraparenchymal abscess, 312, 316
mesh reconstruction, 311, 314
pericranial flap, 311–314 B
radiation necrosis, 312, 317 Bone-anchored hearing aid (BAHA)
rectus muscle injury, 312, 317 aural atresia, 352, 357
scalp abscess, 311, 315 intracranial abscess, 351
skull base reconstruction, 311, 312 Bone flap resorption, 176
SNUC, 311, 314 Box osteotomy, 148
squamous cell carcinoma, 312, 316 Brachytherapy
Anterior temporal lobectomy imaging, 517
choroid plexus changes, 245, 246 rods, 517
description, 244–245 seeds, brain tumors
dominant hemisphere, 244, 245 I-125 interstitial radiation, 214
gliosis, 245, 247 radioactive isotopes, 214
nondominant hemisphere, 244, 245 BrainGate. See Neural interface system
optic pathway changes, 245, 247 Brain imaging
posterior cerebral artery territory infarction, 245, 248 neurodegenerative, neuropsychiatric and epilepsy
Arachnoiditis surgery
arachnoiditis ossificans, 592 anterior temporal lobectomy, 244–248
“empty sac” sign, 591 callosotomy (see Callosotomy)

DOI 10.1007/978-3-319-52341-5
698 Index
Brain imaging (cont.) description, 83

cingulotomy, 220–221 left anterior maxillary sinus wall, 83
corticectomy, 238, 239 nasoantral, 83
DBS, 238, 239 Callosotomy
DBS (see Deep brain stimulation (DBS)) description, 242
epidural motor cortex stimulator, 230 microstructural changes, 242
limbic leucotomy, 222–224 partial, 242, 243
microcatheter subthalamic infusion, 232 via laser ablation, 242, 244
neural interface system, 231 Canaloplasty and meatoplasty, 356
pallidotomy, 219 Carotid endarterectomy (CEA)
prefrontal lobotomy, 217–218 carotid artery restenosis, 650
seizure monitoring electrodes and neuropace, clamp deformity, 646
232–237 conventional carotid endarterectomy, 647
selective amygdalohippocampectomy, 249–250 cranial nerve injury, 646, 651
subcaudate tractotomy, 222–223 description, 646
thalamotomy, 225 expected early postoperative changes, 647
Brain tumors hyperperfusion/reperfusion syndrome, 646
brachytherapy seeds, 214 internal carotid artery velocities, 647
chemotheraphy wafers, 213 localized intimal flap, 646, 648
intraoperative MRI patch endarterectomy, 647
brain shift, 183, 184 patch infection, 646, 650
hyperacute hemorrhage and hemostatic material, post-endarterectomy carotid artery
183, 186 occlusion, 651
laser ablation, 183, 186 recurrent stenosis, 647
transient swelling, after laser ablation, 183, 187 reperfusion syndrome, 646, 649
tumor progression, after laser ablation, 184, 188 saphenous vein graft, 646, 648
tumor resection and contrast leakage, 183, 185 wound infection, 646
Ommaya reservoirs, 208–212 Cerebrospinal fluid shunts, drains and diversion
resection cavities techniques
evolution, 191, 192 atypical ventricular shunts, 267–268
granulation tissue, 201, 202 complications
GRE/SWI sequences, 197 calcified VP shunt catheter, 299
hypertrophic olivary degeneration, 193, 196 Chiari decompression (see Chiari decompression
lesion enhancement, 201 complications)
metastatic glioblastoma, in spinal canal, 201, 207 corpus callosum changes, 282
operative bed hemorrhage, 197, 198 CSF leakage syndrome (see CSF leakage
perioperative infarct, 201–203 syndrome)
peri-resection infarction, 193, 194 hyperostosis, 287, 288
radiation necrosis, 201, 206 intracranial hypotension, 287
retraction-induced vasogenic edema, 193, 195 intraparenchymal pericatheter cysts and interstitial
superficial siderosis, 197, 200 CSF, 295
surgical cavity, blood products, 191–192 intraventricular fat migration, 284
tumor progression, 201, 204–205 isolated ventricle (see Isolated/trapped ventricle)
wounded tumor, 197, 199 MRI-induced programmable valve setting
stereotactic brain biopsy alteration, 285
blood products, 189 shunt-associated infections, 289–291
cavity marker, 189 shunt-associated intracranial hemorrhage and
expected biopsy path enhancement, 189, 190 gliosis, 283–284
tumor seeding, 189, 190 shunt fracture and retained fragments, 294
Burr holes shunt malposition and migration, 292–293
craniostomy, 126 slit ventricle syndrome (see Slit ventricle
description, 126 syndrome)
enhancement, 126, 127 tumor seeding, 298
VP shunt pseudocysts, 260–266
cystoperitoneal and cystoventriculostomy shunts
C internal drainage, arachnoid cysts, 272
Calcified VP shunt catheter ventriculoperitoneal shunt placement, 272
pericatheter dystrophic calcifications, 299 decompression, Chiari malformation
radiographs, 299 cine phase-contrast, 277
Caldwell-Luc procedure posterior fossa decompression, 306
chronic recurrent sinusitis, 83 suboccipital craniectomy, 300
Index 699
endoscopic choroid plexus fulguration (see Choroid lateral malpositioning, 403, 404
plexus fulguration) medial malpositioning, 402, 403
endoscopic septum pellucidum and cyst fenestration perilymphatic fistula, 400, 402
postoperative MRI, 278 receiver-stimulator skull erosion, 402
preoperative T2 MRI, 279 components, 398, 399
ventricular system, 278, 279 insertion, cochlear drill out, 400
EVD (see External ventricular drains (EVD)) Coil embolization, endovascular surgery
lumboperitoneal shunt (see Lumboperitoneal aneurysm coiling, 660, 686, 687
shunting) angiography, pipeline stent insertion, 660
subdural-peritoneal shunt, 271 compaction, 685, 687
syringosubarachnoid and syringopleural shunts, detachable coil, 663
274–275 migration, 688, 689
third ventriculostomy nontarget embolization, 686, 688
defect, Liliequist’s membrane, 277 prolapse, 688
endoscopic fenestration, 277 retained catheter fragment, 689, 688
hemodynamic changes, 277 retained snare, 689, 688
Torkildsen shunt (see Torkildsen shunt) stent-assisted coiling, 658, 660
VP shunts (see Ventriculoperitoneal (VP) shunts) vertebral artery embolization, 663, 670, 671, 687
Cheek and nasolabial fold augmentation Conjunctivodacryocystorhinostomy (CDCR), 43, 44
anterior face and calcium hydroxylapatite Coronoidectomy, 436–437
injection, 7, 9 Corpectomy
anterior face and hyaluronic acid anterior slippage, expandable cage, 536
augmentation, 7, 10 bone graft reconstruction, 533
collagen injection, 7, 11 dislocated bone grafts, 536
coral implants, 7, 8 expandable cage, 535, 536
heterotopic ossification, 7, 17 expandable cage subsidence, 535
HIV lipoatrophy, 7 Harms cage, 533, 534
hyaluronic acid eyelid migration, 7, 17 stackable carbon fiber reconstruction, 535
implant Corpus callosum changes, shunt catheterization
abscess, 7, 14 injury, 282
bone erosion and maxillary sinus scalloping deformity, 282
penetration, 7, 17 swelling, 282
seroma, 7, 13 Corticectomy
inflammation, 7, 16 description, 238
injectable silicone residual lesions, 238, 239
granulomas, 7, 16 tuberous sclerosis and intractable seizures, 238
scars, 7, 16 Cranial vault encephalocele repair
liquid silicone injection, acne scar treatment, 7, 8 description, 146
osteomyelitis, 7, 15 occipital encephalocele resection, 146
polyacrylamide gel polymer treatment, 7, 12 preoperative sagittal, 147
polytetrafluoroethylene filler, 7, 9 Cranial vault surgical remodeling
silicone implant and calcium Barrel stave osteotomies, 142, 143
hydroxylapatite, 7, 8, 12 calcium phosphate cement, 142, 145
Cheiloplasty see Lip reconstruction correction cranioplasty and orbitofrontal
Chemotherapy wafers advancement, 142–144
carmustine, 213 description, 142
Gliadel, 213 endoscopic strip craniectomy, 142, 145
tumor recurrence, 213 orbitofrontal advancement surgery, onlay
Chiari decompression complications cement, 142, 144
arachnoid cyst formation and cerebellar ptosis, 272 posterior cranial vault distraction, 142, 144
pseudomeningoceles, 300 Craniectomy, 140–141
Choroid plexus fulguration Cranioplasty
dilatation, lateral ventricle, 280, 281 hydroxyapatite cement, 132, 134
hydrocephalus, 280 intraoperatively fashioned acrylic, 133
tumor resection, 281 Porex, 132, 136–137
Cingulotomy, 220–221 preformed acrylic, 132, 134
Cochlear implants split-thickness bone graft, 132, 138
complications synthetic bone grafts, 132
facial nerve, 398, 400 synthetic HTR bone graft, 132, 137
implant extrusion, 402, 404 titanium mesh, 132, 135
incomplete insertion, 402 titanium plate, 132, 136
700 Index
Craniotomy E
complications, 128 Ear and temporal bone imaging
description, 128 atresiaplasty, 357–358
dural enhancement and bone flap granulation tissue, auricular reconstruction, 354–355
128, 130 auriculectomy, 353–354
fixation wires, 128, 130 BAHA device, 352
hemicraniotomy, 128 canaloplasty and meatoplasty, 356
hinge craniotomy, 128, 130 cochlear implants (see Cochlear implants)
imaging appearance, 128 endolymphatic sac decompression and shunting, 409
intracranial air, 128 eustachian tube occlusion procedures, 384–385
micro fixation plates, 128, 129 incus interposition, 367, 368
postoperative pneumocephalus, 128, 131 labyrinthectomy, 410–411
skin staples, 128, 129 lateral temporal bone resection, 353, 395, 397
standard types, 128 mastoidectomy (see Mastoidectomy)
temporalis muscle swelling, 128, 131 myringotomy and tympanostomy tubes, 359–360
CSF leakage syndrome ossicular prosthesis, 378–382
description, 297 PORP, TORP and VORP, 369–373
lower chest, 297 repair, perilymphatic fistula, 408
lumboperitoneal shunt placement, 276 stapedectomy, stapedotomy and stapes prosthesis
Cyst decompression, 435 malleus grip prosthesis, 374, 376
Cystic craniopharyngiomas Robinson bucket handle prosthesis, 375
drainage, 318, 319 Schuknecht teflon wire stapes prosthesis, 374, 375
fenestration, 318 smart nitinol wire, 374, 375
infection, 318, 320 susceptibility artifact, 374, 377
postoperative cyst growth, 318, 319 superior semicircular canal dehiscence repair, 413
transcanal atticotomy, 382
tube drainage, cholesterol cysts, 414–415
D vestibular nerve sectioning, 412
Dacryocystorhinostomy and nasolacrimal duct stents Effusions, 166, 167
CDCR, 43, 44 Eminectomy and meniscalplication, 441
dacryocystogram patency, 43–44 Endolymphatic sac decompression and shunting, 409
description, 43 Endovascular surgery
pneumo-orbit with Jones tube, 43, 44 coil embolization (see Coil embolization,
Decompression, spine endovascular surgery)
cordectomy, 537 detachable balloon embolization, 663
corpectomy, 524, 533, 535–537, 550 extracranial carotid artery stents (see Extracranial
facetectomy, 524, 529 carotid artery stents)
laminectomy, 526–528 intracranial arterial stents (see Intracranial arterial
laminoplasty, 532 stents)
laminotomy and foraminotomy, 525 liquid agent and particle embolization
microdiscectomy, 530–531 arteriovenous malformations, 661–662
vertebrectomy, 524, 533–536 incomplete embolization, 636, 637
Deep brain stimulation (DBS) left frontal meningioma, 665
brain stimulator insertion infarct, 226, 229 onyx embolization, 665
electrode migration, 226, 228 retained catheter fragment, 661
subthalamic nucleus stimulation, 226 Silastic beads, 661, 662
ventralis caudalis nucleus stimulator, tantalum powder, 661
226, 227 mechanical stent failure
Detachable balloon embolization, 663 flat-panel CT, 686
Duraplasty and sealant agents fracture, 683, 686
collagen matrix, 154, 155 stent kink, 683, 686
complications, 154 mechanical thrombectomy (see Thrombectomy,
description, 154 mechanical)
photograph, suturable DuraGen, 155 percutaneous sclerotherapy, 666–667
polytetrafluoroethylene (Gore-Tex), 154, 156 vascular plugs, 663, 664
Dysthyroid orbitopathy venous sinus stents, 676, 677
description, 41 Epidural motor cortex stimulator, 230
medial and lateral orbital wall decompression, 41 Eustachian tube occlusion
orbital rim augmentation, 41, 42 catheter migration, 384, 385
paranasal sinus obstruction, 41, 42 hydroxyapatite injection, 384
transnasal endoscopic approach, 41 teflon injection, 384, 385
Index 701
EVD (see External ventricular drains (EVD) gossypiboma, 600–601

Expanded polytetrafluoroethylene (ePTFE), 35 hardware
External brain herniation, 175 displacement, 583
External ethmoidectomy, 84 interbody fusion device retropulsion, 584
External ventricular drains (EVD), 259, 261 lucency, 585
Extracranial carotid artery stents malpositioning, 583, 584
cervical, 672 pseudarthrosis, 585
complications, 677, 684 rod displacement, 583
description, 673 transsacral interbody fusion, 585
intimal hyperplasia, 681, 683 infection
stent occlusion, 682, 684 discitis/osteomyelitis, 589
Extracranial-intracranial revascularization, vascular epidural abscess, 547
surgery hardware removal, 589, 590
direct retroperitoneal abscess, 559, 566
MCA-STA bypass, 628 Staphylococcus aureus, 589
occlusion, 627, 629 intradural inclusion cyst
saphenous vein graft, 627, 628 formation, 591
indirect ovoid cystic mass, 597
ADC maps, 631 neuritis
angiography, 631 left lower extremity weakness, 591
cerebral infarction, 631, 646 MRI, 591
encephaloduroarteriosynangiosis/pial synangiosis, pseudomeningocele and CSF leak
631, 633 CT myelogram, 583, 587
encephaloduromyosynangiosis, 631, 633 management, 587
multiple burr holes, 631 pseudomeningocele, 587
residual/recurrent disc material vs. epidural scar
epidural fibrosis, 591, 593
F sequestered disc fragment, 594
Facetectomy residual/recurrent tumors, 596–597
partial, 529 retained bone fragments, 599
total, 529 retained drill bit
Facial cosmetic surgery broken drill bit fragment, 599, 603
augmentation CT, 599
cheek and nasolabial fold, 7–17 synovial cyst
chin and jaw, 26–28 de novo synovial cyst, 595
forehead, 5–6 puncture and aspiration, 595
lip, 25 FBSS. See Failed back surgery syndrome (FBSS)
materials and imaging features FESS. See Functional endoscopic sinus surgery (FESS)
complications, 1 Flat-back syndrome, 602
fillers and injectables, 1, 4 Forehead augmentation
implants and grafts, 1, 3 description, 5
photographs, facial implants, 1, 2 lateral brow augmentation, 5, 6
rhinoplasty, 18–24 mid-forehead
Facial reanimation calcium hydroxylapatite, 5
free gracilis muscle transfer, 472 polytetrafluoroethylene, 5
SOOF lift, 472–475 Free flap reconstruction
temporalis muscle transposition, 472–475 complications, 123
temporoparietal fascia, 473, 474 description, 123
tensor fascia lata graft implantation, 472, 473 Latissimus dorsi muscle, 123, 124
Failed back surgery syndrome (FBSS) omental, 123, 125
adjacent segment disease, 601 Frontalis suspension ptosis repair, 35
arachnoiditis, 591–592 Frontal sinus cranialization, 100
causes, 582 Frontal sinus trephination, 101
deformity Functional endoscopic sinus surgery (FESS)
flat-back syndrome, 558, 602 anterior, cerebral artery pseudoaneurysm, 91
pedicle subtraction osteotomy, 602 bolgerization, 85
wedge osteotomy, 602 CSF leak, 89
description, 582 description, 84
epidural hematoma draf type I, II and III frontal sinusectomy,
laminectomy, 588 85–88
spinal canal stenosis, 588 empty nose syndrome, 96
702 Index
Functional endoscopic sinus surgery (FESS) (cont.) H

encephaloceles Halo and traction devices
and intraparenchymal hemorrhage, 89 Gardner-Wells device, 538
meningoceles, 89 halo vest, 538
ethmoid artery injury, 91 Harrington, Knodt and Luque rods
intraorbital complications, 90 dislocation, 556
lateralized middle turbinate, 95 flat-back syndrome, 556
medialized lamina papyracea, 92 frontal radiographs, 556
middle turbinectomy, 84, 85 rod fracture, 556, 557
mucocele, 94 Hemicraniectomy, 125, 137, 140, 156
mucosal inflammation, 93 Hemispherectomy
nasoantral window, 85, 88 anatomical, 251, 252
optic nerve injury, 90 description, 251
orbital injury, 90 functional, 251
osteoneogenesis, 95 Hemorrhage and hematomas
pattern, ostiomeatal unit, 84, 85 adjacent epidural, 162
posterior drainage pathway, 85, 86 adjacent intraparenchymal, 162, 163
recurrent polyposis, 94 asymptomatic, 162
retained surgical packing, 88 regional subdural, 162, 163
sphenoidotomy, 85 remote cerebellar hemorrhage, 162, 164
surgical packing material, 88 skull flap, subjacent to, 162, 165
uncinectomy, 84 subgaleal, 162
Hydrogel expander, 65
Hygromas, 166
G Hyperostosis
GAD. See Glutamic acid decarboxylase (GAD) calvarial, 288
Genioplasty dural, 300
combined osteotomy and porous polyethylene, imaging, 287
424, 425
coronal and CT images lengthening,
423, 424 I
shortening, 3D CT image, 424 IMF. See Intermaxillary fixation (IMF)
silicone, 424, 425 Implantable bone stimulators
Glaucoma surgery description, 542
Ahmed valve, 47, 48 frontal and lateral, 542
Baerveldt shunt, 47 Incus interposition
blebs, 47, 49 dislocation, 367, 368
description, 47 osteonecrosis, 367, 368
Ex-PRESS glaucoma shunt, 47, 50 Inferior turbinate outfracture and reduction, 79
glaucoma valve, photo, 48 Intermaxillary fixation (IMF), 432
hemorrhagic suprachoroidal detachments, Intracranial aneurysm muscle wrap
47, 49 growing left P1 segment aneurysm, 635
orbital cellulitis, 47, 49 temporalis muscle, 631, 632
valves drainage, maxillary sinus, 48 Intracranial arterial stents
GliaSite radiation therapy system, 215–216 CT angiography, 670, 673
Glossectomy and mouth floor reconstruction stent stenosis, 682, 684
marginal mandibulectomy, 477 Intracranial hypotension, chronic overshunting
minimal tongue excision and primary closure, 476 diffuse thickening and avid enhancement,
partial glossectomy, 476 meninges, 287
pharyngocutaneous fistula, 493 symptom, 287
sialocele, 476, 478 Intraocular lens (IOL)
squamous cell carcinoma recurrence, 478 cataracts, 56
submandibular gland, 476, 479 components, 56
total glossectomy, 477 implant dislocation, 56, 57
Glutamic acid decarboxylase (GAD), 232 implant dystrophic calcifications, 56, 57
Gossypiboma. See also Retained surgical packing posterior chamber, 56
description, 600 Intraocular silicone injection, 59–60
lumbar stenosis, 600 Intraparenchymal pressure monitor, 157
MRI, 600–601 Intrathecal spinal infusion pump
Index 703
Baclofen pump components, 604 granulation tissue, 493

metastatic disease, 603 horizontal, 490, 492
spinal hypotension syndrome, 603, 604 infected leak, 493
Intraventricular fat migration, 284 postoperative laryngocele, 494
IOL. See Intraocular lens (IOL) recurrent tumor, 493
Isolated/trapped ventricle supracricoid, 490, 492
asymmetric ventricles, 286 total laryngectomy, 477, 491, 493
obstruction level, 286 total pharyngolaryngectomy, 491
right lateral ventricle collapse, 283 types, 488, 492
vertical partial laryngectomy, 489, 492
Laryngoplasty and vocal fold injection
J cartilage graft, 500, 501
Jannetta procedure. See Microvascular decompression “classical” laryngoplasty, 501
Jaw augmentation excess medialization, 500, 501
chin augmentation fat injection, 503
“button” bone graft, 26 hyaluronic acid, 501, 503
silicone implant, 26 hydroxyapatite prostheses, 500, 501
chin implant insufficient medialization, 505
bone erosion, 26, 28 material extrusion, 504
bone formation, 26, 28 material supraglottic migration, 505
and prejowl porous polyethylene implant, 26, 27 medialization laryngoplasty, 500
seroma, 26, 28 micronized acellular human dermis, 504
combined bone and silicone chin implant, 26, 27 montgomery prosthesis, 500, 505
lateral/mandibular angle implants, 26, 28 polytetrafluoroethylene, medialization laryngoplasty,
prejowl implant migration, 26, 27 500, 502
Jones tube, 43, 44 teflon granuloma, 501, 504
types, agents, 501
vocal fold augmentation, injectable calcium
K hydroxylapatite, 502
Keratoprostheses Lateral temporal bone resection
complications, 55 description, 395, 397
description, 55 tumor recurrence, 395, 397
Kpro type 1 and II device, 55 type I, 395, 397
type II, 395, 397
type III, 395, 397
L type IV, 395, 397
Labyrinthectomy Leucotomy. See Prefrontal lobotomy
chemical, 410 Limbic leucotomy, 222–224
transcanal, 410, 411 Lip augmentation
transmastoid, 410 calcium hydroxylapatite, 25
Laminectomy complications, 25
bilateral, 526 polytetrafluoroethylene implants, 25
and duraplasty, 527 Lip reconstruction
hemilaminectomy/unilateral, 526 closure techniques, 453
infarct, 526, 528 perioral myocutaneous flap, 453, 454
spinal cord laceration, 537 radial forearm free flap, 457
Laminoplasty Lumboperitoneal shunting
partial osteotomy, 532 description, 276
unilateral right-sided titanium lamina prosthesis, 532 gravity-actuated horizontal-vertical valve system, 276
Laminotomy and foraminotomy programmable valve, 276
artificially widening L5–S1 neural foramen, 525 pseudotumor cerebri and CSF rhinorrhea, 276
thinning, 525
Laryngeal stents, 499
Laryngectomy M
abscess, pseudoaneurysm, 494 Mandible fractures
anastomotic leak, 493 external fixation, 432, 433
angiolytic laser cordectomy, 488 IMF, 432
aortic graft, 488, 493 maxillomandibular, Erich arch bars, 432
contrast-enhanced CT, 493 open reduction, 432, 433
704 Index
Mandible surgery Maxillary swing

core excision and enucleation description, 110
biopsy, 434 nasopharyngeal carcinoma, 110
brown tumor, mandible, 434 recurrent tumor, 110, 111
coronoidectomy, 436 Maxillectomy and palatectomy
cyst decompression, 435 antibiotic-impregnated beads, 104, 109
distraction, mandibular, 426–427 flap reconstruction, tumor recurrence, 104, 109
eminectomy and meniscalplication, 441 foreign body reaction, 104, 109
fixation, mandible fractures, 432–433 obturator, 104, 105
genioplasty (see Genioplasty) osteomyocutaneous flap reconstruction, 104, 107
mandibular angle augmentation, 425 partial and total, 104, 105
mandibulectomy and mandibular reconstruction, postoperative dacryocystocele, 104, 109
438–440 postoperative pterygopalatine fossa, 104, 108
mandibulotomy, 433 radial forearm, 104, 106
osteotomy Meningogaleal complex, 140–141
sagittal split, 423 Microcatheter subthalamic infusion, 232
vertical ramus, 421–422 Microdiscectomy
Mandibular angle augmentation, 425 description, 530
Mandibular distraction left ligamentum flavum absence, 530
curvilinear distraction device, 426, 427 surgicel mimicking disc sequestration, 531
mature osteogenesis, 426, 431 Microvascular decompression
single-vector distraction device, 426 cranial nerve 8 compression, 643, 645
transport distraction device, 427 failed, 644
Mandibulectomy and mandibular reconstruction glossopharyngeal neuralgia, 643, 644
condylectomy, 438, 439 hemifacial spasm, 643–645
and condylectomy, condylar prosthesis, Teflon, 643–645
438, 439 trigeminal neuralgia, 643, 644
devitalized fibular graft, 438, 439 Middle cranial fossa
graft, abscess, 428, 430 reconstruction
hardware fracture, 438, 440 fat and bone grafts, 336, 337
marginal mandibulectomy, 438 myocutaneous flap, 336, 337
segmental mandibulectomy, 438 titanium mesh and bone graft, 336
TMJ dislocation and accelerated arthritis, temporal lobe encephalomalacia, 336
440, 446 vestibular schwannoma resection, 338–347
tumor recurrence, 434, 438, 440 Mohs micrographic surgery, 122
Mandibulotomy, 433 Montgomery® laryngeal stent®, 499
Marcus Gunn jaw-winking syndrome, 35 Montgomery® salivary bypass tube®, 498
Mastoidectomy Myringoplasty and tympanoplasty
complications graft cholesteatoma, 359, 361
CSF leak and encephalocele, 389, 413 tubes
encephalocele, 389, 394 extrusion, tympanostomy tube, 360
extratemporal cholesteatoma recurrence/inclusion medial dislocation, 360
cyst, 389, 391 metal grommet, 359
facial nerve dehiscence, 392 plastic grommet, 359
facial nerve injury and reparative neuroma, plastic shaft tympanostomy tube, 360
389, 393 type description, 365, 366
graft resorption, 384, 389 type I
granulation tissue, 389, 390 cartilage graft, 361, 363
labyrinthitis ossificans, 398 silastic implant, 363
mucosalized mastoid bowl, 386, 387, 394 temporalis fascia, 361, 362
recurrent cholesteatoma, 389, 391 type II, 363
repair, tegmen, 389, 394 type III
and mastoid obliteration stapes columella, 364, 365
bone dust, 388 tympanoplasty, minor columella, 364, 365
canal-wall-down, 398 type IV, 364, 366
canal-wall-up, 398
drainage tubes, 414
fat graft, 387 N
radical, 386, 387 Nasal packing, 80
simple/partial, 357, 386 Nasal septal button prosthesis, 78
Index 705
Neck dissection with implant, 66, 68

abscess, 461, 467 maxillectomy and flap reconstruction, 66, 67
extended, 461, 463–464 radiation-induced osteosarcoma, 66, 69
lymphocele, 461, 467 radical, 66, 68
modified radical, 461, 464 tumor recurrence, 66, 69
neuropathic joint, 461, 468 Orbital radiation therapy fiducial markers, 70
osteomyelitis, 461, 467 Orbital tissue expanders, 65
pectoralis rotational flap, radical, 464 Orbital wall reconstruction and augmentation
postoperative imaging, 461 bone graft, 36
selective, 461–463 cerebrospinal fluid leak., 36, 40
tongue atrophy, 461, 464 hematic cyst, 36, 39
types, 461–463 infection, 36, 38
Neck imaging inferiorly positioned mesh, 36, 39
arytenoidectomy, 507 medial canthus stabilization device, 36, 38
brachytherapy, 517 mesh deformity, 36, 39
facial reanimation (see Facial reanimation) mucocele, 36, 40
glossectomy and mouth floor reconstruction, nasolacrimal duct obstruction, 36, 40
476–478 porous polyethylene implant, 37
laryngeal framework reconstruction porous structure, 36
hematomas, 508 rectus muscle impingement, 40
miniplates, 508 silicon implant, 36
panorex and 3D CT, 508 titanium mesh, 36, 37
laryngeal stents, 499 wedge implant designs, 36, 38
laryngectomy, 488–494 Orbit imaging
laryngoplasty and vocal fold injection (see dacryocystorhinostomy and nasolacrimal duct stents,
Laryngoplasty and vocal fold injection) 43–44
lip reconstruction (see Lip reconstruction) decompression (see Dysthyroid orbitopathy)
montgomery T-tubes, 497 enucleation, evisceration and globe prostheses
neck dissection, 461–468 components, 61
neck exploration and parathyroidectomy description, 61
failed, 514, 516 globe implant exposure, 61, 64
parathyroid gland autotransplantation, 514 globe implant rotation and inflammation,
recurrent parathyroid adenoma, 470 61, 63
parotidectomy, 469, 470, 473, 474 hollow glass globe implant, 61
reconstruction flaps (see Reconstruction flaps) hydroxyapatite prosthesis, 61
salivary bypass stent, 498 orbital augmentation beads, 61, 63
salivary duct stenting orbital augmentation with silicone implant,
sialendoscopic extraction, 471 61, 63
submandibular duct stent, 471 porous polyethylene implant, 61, 62
Sistrunk procedure (see Sistrunk procedure) scleral cover shell, 61, 63
thyroidectomy, 512–515 silicone implant, 61, 62
tonsillectomy and adenoidectomy, 480–483 eyelid weights
tracheoesophageal puncture and voice prostheses, complications, 31
495–496 facial nerve deficit, 31
vagal nerve stimulator, 518 left cranial nerve VII palsy, 31, 32
Neural interface system, 231 frontalis suspension ptosis repair, 35
glaucoma surgery, 47–50
intraocular silicone injection, 59–60
O IOL implants (see Intraocular lens (IOL))
Ommaya reservoirs keratoprostheses, 55
catheter-associated cyst, 208, 212 orbital radiation therapy fiducial markers, 70
catheter infection, 208, 210 palpebral spring
components, 208, 209 description, 33
description, 208 eyelid, 33–34
infection, 208 scleral buckles, 51–54
methotrexate extravasation, 208, 211 strabismus surgery, 45–46
Orbital exenteration subretinal gas/anterior chamber migration, 58
description, 66 surgical aphakia, 58
and facial implant, 66 tissue expanders, 65
graft necrosis, 66, 68 wall reconstruction and augmentation, 36–40
706 Index
Ossicular prosthesis complications Partial ossicular reconstruction prosthesis (PORP)

detachment, stapes prosthesis, 378, 379 Applebaum, 371, 372
dislocated Black oval-top, 372, 381
PORP, 378, 380 dislocated, 380, 381
TORP, 378, 381 migration, TORP, 378
extruded TORP, 378, 381 stapes, 378
lateralized stapes prosthesis, 379 tympanic membrane, 378, 379
migration, PORP and TORP, 378 Percutaneous sclerotherapy
perilymphatic fistula, 378 alcohol sclerotherapy, 666
prosthesis fracture, 382 MRI, 666–667
recurrent cholesteatoma, TORP, 378, 381 surgical resection, 665
stapes prosthesis, 378 Percutaneous spine treatments
tympanic membrane dehiscence, 378, 382 adjacent level vertebral body fracture,
vestibular perforation, 378 kyphoplasty, 609
Osteoplastic flap, frontal sinus obliteration cement extravasation
cosmetic deformity, 97, 99 degenerative changes, 609
description, 97 disc space cement leakage, 609, 611
expected appearance, 97 paravertebral extravasation, 609, 611
extruded packing material, 97, 99 spinal canal cement leakage, 611
frontal sinus obliteration, 97, 98 cement intravasation and embolism
retained secretions, 97, 98 chest imaging, 609
Osteotomy pulmonary embolism, 612
sagittal split, 423 fusion
vertical ramus homogeneously hyperdense material, 593
muscle atrophy, 421, 422 OptiMesh, 614
TMJ dysfunction, 421, 422 percutaneous perineural cyst decompression, 616
sacroplasty, 524, 613
vertebral augmentation (see Vertebral
P augmentation)
Pallidotomy, 219 Perilymphatic fistula repair, 408
Paranasal sinuses and nasal cavity Pneumatic retinopexy, 58
Caldwell-Luc procedure, 83 PORP. See Partial ossicular reconstruction prosthesis
decompression and drainage, 102 (PORP)
enucleation and ostectomy, 102, 103 Posttraumatic rhinoplasty
external ethmoidectomy, 84 cortical bone reconstruction, 75, 76
FESS (see Functional endoscopic sinus surgery description, 75
(FESS)) nasal bone fracture reconstruction,
frontal sinus cranialization, 100 75, 76
frontal sinus trephination, 101 Prefrontal lobotomy, 217–218
inferior turbinate outfracture and reduction, 79 Pseudoaneurysm, 169
maxillary swing, 110–111 Pseudomeningoceles, 168
maxillectomy and palatectomy, 104–109
nasal packing, 80
nasal septal button prosthesis, 78 R
osteoplastic flap, frontal sinus obliteration, 97–99 Reconstruction flaps
paranasal sinus stents, 101 aerodigestive track, 453, 458
posttraumatic rhinoplasty, 75–76 colonic interposition, 457, 458
residual/recurrent lesion, 102, 103 complications, 454
rhinectomy, 81 facial soft-tissue defects, 453
septoplasty, 77–78 fasciocutaneous rotation advancement flap,
sinus lift procedure, 82 454, 455, 458
Paranasal sinus stents, 101 gastric transposition, 457
Parotidectomy myocutaneous
facial nerve sacrifice, 470, 473 flap neopharynx, 457, 459
parotid pleomorphic adenoma recurrence, free flap, 453, 456, 457
469, 470 rotational flap, 456
partial superficial, 469 osteomyocutaneous
skin cancers and chronic inflammatory diseases, 469 and bone grafts, 453
superficial parotidectomy, graft reconstruction, 469 flap, 453, 454, 456
total parotidectomy, 469, 470 pectoralis major muscle flap, 453
Index 707
rugal folds and haustra, 453 occipital nerve stimulator, 117–118

temporalis flap, 455 pseudomeningoceles, 168
tissue flaps types, 454 rotational galeal flap scalp reconstruction, 123
tumor recurrence, 459 scalp tissue expander, 119
types, 453, 454, 458 scalp tumor recurrence, 125
Retained surgical packing, 88 subdural drainage catheters, 158
Rhinectomy, 81 Sunken skin flap syndrome, 174
Rhinoplasty temporal fossa implant, 120–121
cellulitis, 18, 22 tension pneumocephalus, 159
cranial nerve V2 injury, 18, 23 textiloma, 173
description, 18 Scalp tissue expander, 119
dorsal augmentation, bone, 18, 19 Scleral buckles
filler, 18, 21 combined silicone rubber band and sponge, 51, 52
fistula implant, 18, 21 description, 51
frontal radiograph, 18, 23 hydrogel
implant abscess, 18, 22 fragmentation and migration, 51, 54
implant extrusion, 18, 22 hydration and expansion, 51, 54
lateral osteotomy, 18 infected, 51, 53
nasal cavity, turbulent, 18, 24 silicone rubber encircling, 51–52
nasal obstruction, 18, 23 silicone sponge scleral buckle, 51, 52
open rhinoplasty, 18 tantalum clip, 51, 53
polytetrafluoroethylene implant, 18, 21 Seizure monitoring electrodes and neuropace
retained foreign body, 18, 21 depth electrode, 232, 235
silicone dorsal tip and columellar nasal implant, description, 232
18, 20 electrode grids, 234
tip augmentation, bone, 18 electrode strips, 233
foramen ovale electrodes, 232, 235
hematoma, 233, 236
S infected electrodes, 233, 237
Sacroplasty NeuroPace, 232, 236
cement, bilateral sacral ala, 613 Selective amygdalohippocampectomy
complications, 613 description, 249
description, 613 visual pathway injury from laser ablation, 249, 250
Scalp and cranium imaging Septoplasty
absorbable hemostatic agents, 149–153 complications, 77
air leak, 160, 161 description, 77
autocranioplasty, 139 nasal stents, 77, 78
bone flap resorption, 176 septoplasty perforation, 77, 78
box osteotomy, 148 septum, nasal obstruction, 77
Burr holes, 126, 127 Shunt-associated intracranial hemorrhage and gliosis
cranial vault predisposing factors, 283
encephalocele repair, 146–147 subdural hemorrhage, 283, 284
surgical remodeling, 142–145 ventriculomegaly and effacement, sulci, 296
craniectomy, meningogaleal complex and Shunt catheter
suboccipital craniectomy, 140–141 associated infections
cranioplasty (see Cranioplasty) cellulitis and subcutaneous abscesses, 289, 291
craniotomy (see Craniotomy) intraperitoneal abscess, 291
duraplasty and sealant agents, 154–156 meningitis, 289
effusions, 166, 167 ventriculitis, 289, 290
entered orbit, 160 fracture and retained fragments
external brain herniation, 175 detached intracranial shunt catheter
free flap reconstruction, 123–125 fragment, 300
frontal sinus, entered, 160 migrated catheter fragments, 292, 297
hemorrhage and hematomas, 162–165 retained infected catheter fragment, 289
hygromas, 166 malposition and migration
infection bowel perforation, 292, 293
cranioplasty prosthesis, 170, 172 catheter tip projection, 292
craniotomy bed, 170–172 distal shunt catheter migration, 292
intracranial pressure monitor, 157 laparotomy, 292
Mohs micrographic surgery and skin grafting, 122 retracted catheter, 292, 294
708 Index
Silastic beads, 661, 662 heterotopic ossification, 567, 571

Sinonasal undifferentiated carcinoma (SNUC), lateral view, lumbar spine, 570
311, 314 NUBAC, 573
Sinus lift procedure prestige cervical spine total disc prosthesis, 568
bone graft material, 82 radiolucent core, 567
description, 82 subsidence, 567
sinusitis and oroantral fistula, 82 vertebral fracture, 571
Sistrunk procedure Stabilization and fusion, spine
abscess, 487 anterior fusion
recurrent thyroglossal duct cyst, 486 anterior cervical discectomy and
surgical defect, 486 fusion (ACDF), 547
Skin grafting, 122 bone graft subsidence, 547, 549
Skull base and cerebellopontine angle imaging iatrogenic spinal cord transection, 547, 549
anterior craniofacial resection, 311–317 infection, 547, 548
cystic craniopharyngiomas, 318–320 lumbar spine, 547
middle cranial fossa anterolateral fusion
approach, 336 adjustable plate system, 550
reconstruction, 336–337 Kaneda device, 550
vestibular schwannomas bone graft materials
radiosurgery, 348 allograft bone chips, 540
surgical approaches, 338–347 autologous bone graft, 539
Slit ventricle syndrome, 287 composite Mozaik moldable morsels, 541
SNUC. See Sinonasal undifferentiated carcinoma DBX putty, bone crouton, 539, 541
(SNUC) demineralized bone matrix, 539
Spinal cord stimulators local vertebral body bone harvest, 540
cervical, 528, 547 mature bone graft fusion, 540
description, 605 recombinant BMP-induced osteolysis, 541
infected lead, 606 craniocervical fusion
thoracic, 605 atlantoaxial fusion, 543
Spine imaging hardware loosening, 546
categories, surgery, 523, 524 indications, 543
decompression (see Decompression, spine) occipital screw intracranial penetration, 545
dynamic facet replacement occipitocervical fusion, 543–546
posterior, 579 uncoiled sublaminar wire, 543, 544
TOPS, 579 vertebral canal entry, 549
dynamic rods halo and traction devices, 538
complications, 580 Harrington, Knodt, and Luque rods, 556
Dynesys, 580 implantable bone stimulators, 542
dynamic stabilization and miscellaneous devices, interbody fusion
567–572 ALIF, 564, 566
FBSS (see Failed back surgery syndrome (FBSS)) disadvantage, 561
intrathecal spinal infusion pump, 603–604 femoral ring allograft, 561
nucleus pulposus replacement, 573 PLIF, 563, 566
percutaneous (see Percutaneous spine treatments) stalif, 565, 566
posterior dynamic stabilization devices tapered LT-cage, 562
Coflex, 574, 577 threaded cage, 562
DIAM, 574, 576 threaded titanium pin, 566
dislocated coflex, 578 TLIF, 563, 566
interspinous spacers, 576, 578 transsacral fusion, 565, 566
isobar, 574, 575 XLIF, 564, 566
X-Stop, 574 Zero P, 547
spinal cord stimulators, 605–606 posterior fusion
stabilization and fusion (see Stabilization and fusion, facet screws, 551, 555
spine) medial malpositioning, 551
total disc replacement pedicle hooks, 555
adjacent-level disc herniation, 567, 572 pedicle screws, 551–553
advent cervical spine total disc prosthesis, 569 wire fixation, 554
ankylosis, 567, 571 screw fixation, dens fractures, 542
anterior migration, 570 VEPTR (see Vertical expandable prosthetic titanium
Charite lumbar spine total disc prosthesis, 569 rib (VEPTR))
Index 709
vertebral stapling Thrombectomy, mechanical

C-shaped staples, 559 complication, 667
description, 559 contrast stain, 667
Stereotactic brain biopsy CTA, 668
blood products, 189 hemorrhage and contrast stain, 667
cavity marker, 189 residual contrast staining, 667, 670
expected biopsy path enhancement, 189, 190 Thyroidectomy
tumor seeding, 189, 190 abscess, 513
Strabismus surgery fluid collection, 513
description, 45 hemithyroidectomy, 511–513
morphology, 45 ipsilateral subtotal resection, 511
postoperative I-131 total body scans, 512
infection, 45, 46 near-total thyroidectomy, 511, 512
rectus muscle rupture, 45 recurrent papillary thyroid carcinoma, 513
rectus transposition, 45 right strap muscle resection, 512
Y splitting, 45 thyroglossal duct remnant, 512
Subcaudate tractotomy, 222–223 types, 511
Subdural drainage catheters, 158 vocal cord paralysis, 513
Subdural-peritoneal shunt Tissue expanders, 65
chronic subdural hematomas, 271 Tonsillectomy and adenoidectomy
complications, 271 axial fat-suppressed T2 and T1, 480
Suboccipital craniectomy, 140–141 cine MRI, 480, 481
Sunken skin flap syndrome, 174 flap reconstruction, 481
Superior semicircular canal dehiscence repair, 413 indications, 480
Surgical aphakia, 58 postoperative infection, 483
Syringopleural shunt, 274–275 recurrent enlargement, 481
Syringosubarachnoid shunt, 274–275 velopharyngeal insufficiency, 480, 482
Torkildsen shunt
description, 269
T internal shunt, 269
Temporal fossa implant Total ossicular reconstruction prosthesis (TORP)
methyl methacrylate, 120, 121 Black oval-top, 372
porous polyethylene, 120 cortical bone sculpted, 371
silicone, 120, 121 dislocated, 378, 381
soft tissue deficiency, 120 extruded, 381
Temporomandibular joint (TMJ) surgery Goldenberg, 371
arthroplasty manubrium, malleus, 367, 369
Lorenz prosthesis, 445 migration, PORP, 378
prosthesis, 445 ossicular chain reconstruction, 369
synthes total joint prosthesis, 446 recurrent cholesteatoma, 378, 381
costochondral graft reconstruction Tracheoesophageal puncture and voice prostheses
resorption, rib graft, 443 Blom-Singer voice prosthesis, 496
rib graft degenerative disease and “esophageal speech”, 495
demineralization, 443 migration, 495, 496
discectomy, 442 provox voice prosthesis, 495
disc implant and prosthesis failure Transcanal atticotomy, 382
implant intracranial migration, 447, 448 Transsphenoidal tumor resection
implant perforation, 448 approach, 321, 322
loosening and dislocation, 447 bone remodeling, 321, 323
pseudoarthrosis, 447, 449 complications
teflon granuloma, 448 carotid artery injury, 327, 330
disc replacement implants cerebrospinal fluid leak, 328, 333
silastic implant, 444 chiasmopexy, 328, 334
types, 444 fibrosis, 328, 335
hemiarthroplasty GRE and SWI, 327
glenoid implant, 445 hematoma, 327, 329
ramus-condyle unit implant, 445 infection, 327, 332
Tension pneumocephalus, 159 merocel migration and brainstem compression,
Textiloma, 173 327, 331
Thalamotomy, 225 optic chiasm ptosis, 328, 334
710 Index
Transsphenoidal tumor resection (cont.) Ventriculoperitoneal (VP) shunts

optic nerve ischemia, 328, 334 Codman Hakim programmable shunt valve, 264
pituitary stalk transection, 328, 333 complications, 260
postoperative fibrosis, 328, 335 delta 1.5 valve VP shunt, 263
sellar hematomas, 327 MRI, 264, 266
sinus inflammation, 327, 332 normal nuclear medicine shunt study, 260, 296
suprasellar fat graft, 327, 331 programmable valves, 260
suprasellar fat graft, 327, 331fat graft, 321, 323 “shuntogram”, 260
granulation tissue, 321, 325 shunt series, 260, 262
merocel packing, 321, 324 strata valve programmable shunt, 264, 285
metal debris, residual, 321, 322 valve performance level setting chart, 265
pedicled mucosal flap, 321, 324 ventriculoperitoneal shunt components, 265
subtotal resection, 321, 326 Ventriculosubgaleal shunt, 268, 270
titanium mesh sellar reconstruction, 321, 325 VEPTR. See Vertical expandable prosthetic titanium rib
transventricular-transsphenoidal, 321, 323 (VEPTR)
Tube drainage, cholesterol cysts Vertebral augmentation
drained cholesterol cyst, 414, 415 increased vertebral body height, 610
trans-sphenoidal, 414 kyphoplasty/vertebroplasty, 609
polymethylmethacrylate cement
injection, 609
V skyphoplasty, 524, 609
Vagal nerve stimulator Vertebrectomy
complication, 518 partial, residual tumor, 596
fontal neck radiograph, 518 resection, thoracic vertebra, 611
Vascular clamp Vertical expandable prosthetic titanium rib (VEPTR),
metallic extracranial carotid, 652 560
Selverstone clamp, 652, 653 Vestibular nerve sectioning, 412
Vascular plugs Vestibular schwannomas
Amplatzer device, 663 radiosurgery, 348
right extracranial vertebral artery, 663, 670 resection
Vascular surgery encephalocele, 339, 344
aberrant right subclavian artery, left aortic arch endolymphatic sac fluid signal loss, 339, 345
hybrid procedures, 653 fat graft aseptic lipoid meningitis, 338, 343
reconstruction, 653 fat graft necrosis, 338, 342
adjustable vascular clamp, 652–653 infarction, 339, 347
aneurysm clips (see Aneurysm clips) labyrinthitis, 339, 345
artificial bypass grafts, 653, 655 labyrinthitis ossificans, 339, 346
carotid body stimulator, 652 mastoid entry and cerebrospinal fluid leak,
CEA (see Carotid endarterectomy (CEA)) 339, 343
extracranial-intracranial revascularization (see middle cranial fossa approach, 338, 339
Extracranial-intracranial revascularization, pseudomeningocele, 339, 344
vascular surgery) residual schwannoma, 338, 341
intracranial aneurysm muscle wrap, 634–635 retrosigmoid approach, 338, 341
microvascular decompression (see Microvascular translabyrinthine approach, 338, 340
decompression) venous sinus thrombosis, 339, 347
right aortic arch repair, aberrant left wound abscess, 339, 346
subclavian artery, 653 Vibrating ossicular prosthesis (VORP)
Venous sinus stents conductive and mixed hearing loss, 351
self-expandable/balloon-expandable stents, 677, 684 extracranial magnet, 351
transverse sinus stent, 676, 677 mastoidectomy, 386
Ventricular shunts VP shunts. See Ventriculoperitoneal (VP) shunts
aqueductoplasty and stenting, 279
atrial, 267
fourth, 286, 300, 302 W
pleural, 267–268, 274 Wallerian degeneration, 242, 249
vesical, 267 Wounded tumor syndrome, 197, 199

Atlas of Postsurgical Neuroradiology - Imaging of The Brain, Spine, Head, and Neck (PDFDrive)

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Atlas of Postsurgical Neuroradiology - Imaging of The Brain, Spine, Head, and Neck (PDFDrive)

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Daniel Thomas Ginat

Imaging of the Brain,

ISBN 978-3-319-52340-8 ISBN 978-3-319-52341-5 (eBook)

Library of Congress Control Number: 2017943020

© Springer International Publishing Switzerland 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

This book is dedicated to my wife Ann-Margret and our

Radiologists and clinicians caring for patients have a plethora of references

Durham, NC, USA James M. Provenzale, M.D.

Chicago, IL, USA Daniel Thomas Ginat

We thank the following individuals for contributing cases, photographs, or

Nishant Agrawal, M.D.

We also thank the following companies for providing device images:

1 Imaging of Facial Cosmetic Surgery�������������������������������������������� 1

11 Imaging of Postoperative Spine���������������������������������������������������� 523

Elizabeth Blair, M.D. Department of Surgery, Section of Otolaryngology-­

Rod J. Oskouian, M.D. Department of Neurosurgery, Swedish Neuroscience

1.1  verview of Facial Cosmetic

C.J. Schatz, M.D., FACR (*)

Table 1.1 Implants and grafts

Table 1.2 Fillers and injectables

Hyaluronic acid Injectable gel CT: water attenuation; subcutaneous fat

Fig. 1.2 Mid-forehead augmentation with polytetraflu­

Fig. 1.4 Lateral brow augmentation. Coronal CT image

Fig. 1.3 Mid-forehead augmentation with calcium hydroxy­

1.3  heek and Nasolabial Fold

Fig. 1.5 Cheek augmentation with coral implants. Axial

Fig. 1.6 Silicone implant cheek augmentation. Axial CT

Fig. 1.8 Anterior face and nasolabial fold calcium

Fig. 1.9 Nasolabial fold polytetrafluoroethylene filler.

Fig. 1.13 Combined silicone implant and calcium

Fig. 1.14 Cheek implant seroma. Axial (a) and coronal

Fig. 1.19 Injectable silicone granulomas. Axial CT

Fig. 1.20 Cheek implant bone erosion and maxillary

1.4 Rhinoplasty ene (Fig. 1.27), and fillers (Fig. 1.28). The implants

Fig. 1.23 Lateral osteotomy rhinoplasty. Axial CT image

Fig. 1.29 Retained foreign body. The patient presented

Fig. 1.32 Implant extrusion.

Fig. 1.34 Hardware deformity. Frontal radiograph shows

Fig. 1.33 Cranial nerve V2 injury. The patient presented

Fig. 1.35 Nasal obstruction after rhinoplasty. Coronal

Fig. 1.38 Lip augmentation with calcium hydroxyapa-

Fig. 1.40 Chin augmentation with silicone implant.

Fig. 1.41 Combined bone and silicone chin implant.

Fig. 1.42 Chin and prejowl porous polyethylene implant.

Fig. 1.45 Chin implant bone erosion. Sagittal CT image

Fig. 1.46 Prejowl implant migration. Coronal CT image

Fig. 1.44 Chin implant seroma. Axial CT image shows

Fig. 1.47 New bone formation. Axial CT image shows

Further Reading Constantian MB, Clardy RB (1996) The relative impor-

Cheek and Nasolabial Fold

Bastidas N, Zide BM (2010) The treachery of mandibular

Berghaus A, Stelter K (2006) Alloplastic materials in rhi-

D.T. Ginat, M.D., M.S. (*)

© Springer International Publishing Switzerland 2017 31

2.2 Palpebral Springs via orbitotomy and consists of a palpebral branch

2.3  rontalis Suspension Ptosis

Fig. 2.4 Bone graft. Coronal CT image shows graft

Fig. 2.9 Medial canthus stabilization. Axial CT image

Fig. 2.8 Wedge implants. Sagittal T1-weighted (a) and

Fig. 2.11 Hematic cyst. Coronal CT image shows a right

Fig. 2.14 Rectus muscle impingement. Coronal CT

Durham, NC, USA James M. Provenzale, M.D.

Chicago, IL, USA Daniel Thomas Ginat

1 Imaging of Facial Cosmetic Surgery�� 1

11 Imaging of Postoperative Spine�� 523

Elizabeth Blair, M.D. Department of Surgery, Section of Otolaryngology-

1.1 verview of Facial Cosmetic

Fig. 1.2 Mid-forehead augmentation with polytetraflu

Fig. 1.3 Mid-forehead augmentation with calcium hydroxy

1.3 heek and Nasolabial Fold

1.4 Rhinoplasty ene (Fig. 1.27), and fillers (Fig. 1.28). The implants

2.2 Palpebral Springs via orbitotomy and consists of a palpebral branch

2.3 rontalis Suspension Ptosis

2.5 Orbital Decompression paranasal sinuses may also be observed on

2.6 Dacryocystorhinostomy via a dacryocystogram (Fig. 2.21). Surgical suc-

2.7 Strabismus Surgery The effects of rectus transposition can be appre-

2.8 Glaucoma Surgery a

2.10 Keratoprostheses device composed of a polymethyl methacrylate

2.11 Intraocular Lens Implants a

2.12 Surgical Aphakia 2.13 Pneumatic Retinopexy

2.12.1 Discussion 2.13.1 Discussion

2.15 Evisceration, Enucleation, including hollow glass spheres (Fig. 2.50).

2.17 Orbital Exenteration with removal of structures surrounding the orbit,

3.1 asal Fracture Reconstruction

3.3 asal Septal Button

3.4 Inferior Turbinate coagulates the inferior turbinate submucosa.

3.6 Rhinectomy Prosthetic rehabilitation can be an alternative to flap

3.7 Sinus Lift Procedure dome-shaped configuration on coronal images

3.8 Caldwell-Luc Procedure Historically, the Caldwell-Luc procedure was

3.9 External Ethmoidectomy 3.10 F

3.11 FESS Complications

3.11.2 Discussion presence of sinus opacification contiguous with

3.11.3 Discussion result from direct injury to orbital vessels, ethmoid

3.11.4 Discussion retract into the orbit, resulting in intraorbital hem-